IN THE CASE OF: BOARD DATE: 6 October 2021 DOCKET NUMBER: AR20200007608 APPLICANT REQUESTS: the following: * correction of her National Guard Bureau (NGB) Form 22 (National Guard Report of Separation and Record of Service) to reflect her highest education level successfully completed as graduate level studies * completion of multiple Line of Duty (LOD) investigations * in effect, duty-related physical disability retirement or separation APPLICANT'S SUPPORTING DOCUMENTS CONSIDERED BY THE BOARD: * DD Form 149 (Application for Correction of Military Record) * multiple self-authored statements * numerous pages of email correspondence * numerous sets of orders * multiple DD Forms 214 (Certificate of Release or Discharge from Active Duty) * numerous Standard Forms 600 (Chronological Record of Medical Care) * multiple DA Forms 2173 (Statement of Medical Examination and Duty Status) * numerous DA Forms 2166-8 (Noncommissioned Officer Evaluation Report (NCOER) * multiple DA Forms 3348 (Physical Profile) * multiple Physical Profile Record forms * DA Form 199 (Informal Physical Evaluation Board (PEB) Proceedings) * DA Form 2823 (Sworn Statement) * numerous orthopedic, operative, and radiology reports * numerous memoranda from her unit, medical entities, self-authored, and other sources * National Guard Bureau (NGB) Form 22 * NGB Form 23B (Army National Guard (ARNG) Retirement Points History Statement) * Department of Veterans Affairs (VA) Rating Decision * multiple records from * numerous additional documents, totaling in excess of 1,000 pages FACTS: 1. The applicant states: a. Her NGB Form 22 contains an error relating to her education level. She has a Master’s Degree in clinical psychology from as well as a chemical dependency counselor certificate at a Master’s level, which are not reflected on her NGB Form 22, as it shows her highest education level successfully completed is 4 years of college. Her former ARNG unit in Kentucky (KY) failed to update her records and she feels as though they are trying to take her level of education away from her. b. She is requesting a review of her medical records and physical disability rating. She understands that while military standards and VA standards are different in terms of ratings, within 1 year of separation from the military she went from a VA rating of 20 percent to 80 percent based on multiple physical issues that occurred during her time in service. She was medically discharged due to a permanent injury to her shoulder and received no disability rating from the Army. She was advised that much of the reason was that no LODs were completed by her ARNG units, despite continued medical treatment. c. There are numerous times when LODs were not finished and filed or not started at all, requiring her in many cases to utilize her personal Tricare insurance and follow-up with the VA and her local healthcare providers. The following are the three most significant injuries where LODs were not completed. d. She injured her shoulder during annual training in Oregon/Washington in 2016, leading to her separation. She made her medical section leader aware of the situation and also the readiness noncommissioned officer in charge (NCOIC) and the commander. No exam was completed and no LOD was initiated. She didn’t go to her doctor until the next week. She was also made to take an Army Physical Fitness Test (APFT) even though she had a good one on records because she was supposed to go to a school 2 months later. At that time, she had discussed her injury throughout movement with her medical NCO and had made it clear that her shoulder and arms were hurting badly. She continued to see an outside orthopedic provider and submitted records to her unit without fail. e. In addition to this, she slipped and fell on the ice while carrying her gear and uniform to her car to leave for drill on the morning of 3 February 2018, and did not make it to drill. Her husband texted the medics and Sergeant First Class (SFC) as soon as it happened and later sent in medical verification/documentation. This fall definitely aggravated her shoulder injury and she was post-surgery at that point. Because she did not make it to drill, it was listed as “split training,” so she was not able to get an LOD for that either. f. She injured her head in 2010 and a final LOD was not finished or filed. She was actually hit in the head with another Soldier’s rifle after he yanked on the sling which had been caught on a bus chair. She saw stars and was initially knocked down. She passed out numerous times and was treated at the Troop Medical Clinic (TMC) in Balad, Iraq. Her weapons were taken from her and there was a minimal delay in movement for the entire brigade. Yet, no LOD or incident report were completed by the unit. Although she continues to have headaches, they are uncomfortable, but mostly manageable. She rarely had headaches prior to this event. An LOD was initiated by the provider at the demobilization site, but was never completed or submitted by her unit. Other conditions now contribute to her headaches as well. g. She sustained a knee injury in 2009 during pre-mobilization and incurred numerous aggravations of the knee injury while mobilized in Baghdad, Iraq. he made several visits to the TMC at Fort McCoy and Camp Shelby, as well as the TMC at Forward Operating Base (FOB) Prosperity, in Iraq. n LOD was initiated by a provider during demobilization, but was never completed or submitted by her unit. despite the fact that an LOD was not completed, she was still able to use all of her medical records once enrolled with the VA at the Lexington, KY, and was able to get a 20 percent service-connected disability rating for this injury soon after initiating VA treatment. She understands the rating criteria would be different with the VA, but an LOD was not completed for this injury. he also has additional issues with her back and ankle with injuries occurring while engaged in military training for which no LODs were submitted. h. She would like to apologize in advance for the volume of documents. She realizes she has included many records (and has even more), but when she submitted her paperwork to the Physical Evaluation Boards (PEB) prior to separation, both representatives in each appeal process advised her it was too much data and limited what was submitted. She has enclosed copies of health service memoranda, board review information, military career history information, as well as medical records. She regrets that she does not know what specifically may be needed. She has many records that correspond to her medical treatment at varying locations and also at several different timeframes. She apologizes for the multiple sticky notes placed on documents. She would like validation from the Army that her service caused her physical disability. i. Several of her NCOERs also reflect her command’s errors. They tend to list personal accomplishments on them, but fail to load documents into the Interactive Personnel Electronic Records Management System (iPERMS) or other systems, and list “continued perseverance through training despite injury” (to her bruised and swollen ankle), but do not take the time to complete an LOD, especially when she is a medic and her section can assist with her needs. As a medic in her unit, she was the acting section leader for several years, sending all of her personal medical records (and those of all other Soldiers) to their State and brigade medical providers and technicians. They were without a section leader for most of the last 3+ years that she was in the ARNG. j. She would like some validation as she continues to have more physical difficulty and experiences mobility issues with pain daily. This also causes further difficulty with the performance of her civilian job duties, with possible retirement still a few years away. Most of all, she would like to see some changes in medical care and procedures with ARNG and U.S. Army Reserve (USAR) Soldiers. Her unit failed her, as did the Army. She served honorably with two deployments and feels as if she were abandoned and discarded once she was no longer of value to her unit. She took pride in all that she accomplished, but now it does not seem that significant. Physical pain and mental stress from feeling as though the ARNG and the Army did not care enough to help her are reminders of all her injuries that occurred while serving and all the time lost with her family and children. To some extent, she believes that writing to the Board will probably not help her, but she is hopeful that at the least, the Board will look at her case and similar cases from other former service members and find some way of ensuring that those who are injured while in service get their medical needs met. Thank you for your time and consideration. 2. Correction of the NGB Form 22 is not a function that falls under the purview of the Army Board for Correction of Military Records (ABCMR) and will not be further discussed in this record of proceedings. 3. The applicant enlisted in the KYARNG on 17 August 2007. 4. Military Entrance Processing Station Orders 8029015, dated 29 January 2008, ordered the applicant to initial active duty for training (IADT), with reporting to basic combat training (BCT) at Fort Jackson, SC, on 7 February 2008 and reporting to advanced individual training (AIT) at Fort Sam Houston, TX, on 21 April 2008. 5. Multiple SF 600s show the following: a. The applicant was seen at Brooke Army Medical Center (BAMC) on 18 June 2008 for complaints of pain in both arms and legs for the past 4 months. She states she had arm pain for the past month and soreness at varicose veins. She was seen by the doctor 4 weeks ago for right biceps tendonitis, but has not decreased push-ups and has been using Ibuprofen and ice. She was diagnosed with right biceps tendonitis and released without limitations. b. She was again seen at BAMC on 26 August 2008 with complaints of right arm pain that radiates to the right shoulder and back for the past 3-4 months and a left knee that feels like it is slipping when she walks for the past week. She denied pain to the left knee. There was no left knee joint swelling, she was able to straighten the left knee and it did not suddenly lock up. Images of the right shoulder and left knee were ordered. Both showed no obvious fracture or dislocation and were unremarkable. She was released without limitations. 6. A DD Form 214 (Certificate of Release or Discharge from Active Duty) shows she was honorably released from IADT on 24 September 2008 and transferred back to the KYARNG. She was awarded the military occupational specialty (MOS) 68W (Health Care Specialist). 7. Boone National Guard Center Orders 016-037, dated 16 January 2009, ordered the applicant to active duty for special work (ADSW) for pre-mobilization medical training at Fort McCoy, from 2 February 2009 through 26 February 2009. 8. A DA Form 1059 (Service School Academic Evaluation Report), dated 26 February 2009, shows the applicant successfully completed 68W pre-deployment training from 15 February 2009 through 26 February 2009. 9. A DD Form 214 shows the applicant was ordered to active duty in support of Operation Iraqi Freedom (OIF) on 1 May 2009. 10. Multiple medical records from May 2009 show the following: a. The applicant was sent to the with knee pain on 13 May 2009. Magnetic Resonance Imaging (MRI) was ordered for the left knee after the applicant relayed a history of left knee pain and trauma. The impressions were of degenerative changes about the patellofemoral compartment. There was an osteochondral defect with associated bone bruising over the anterior lateral femoral condyle about the lateral trochlear groove; small effusion. b. A DD Form 689 (Individual Sick Slip) dated 14 May 2009 and stamped by a Medical Task Force Shelby doctor, shows the applicant had left knee pain and was issued a temporary physical profile for no running, jumping, marching, or high impact activities for 1 week. An additional Work Status Report Form, dated 14 May 2009, shows a diagnosis of left knee bone bruise and osteochondral defect. 11. Camp Shelby Joint Forces Training Center Orders 173-505, dated 22 June 2009, deployed the applicant inn a temporary change of station (TCS) status to Iraq in support of Operation Iraqi Freedom effective 23 June 2009. 12. An SF 600 shows the applicant was seen at the 332nd Expeditionary Medical Group (EMDG) on 9 March 2010 for syncope (fainting). She reported being hit on the head with a swinging rifle on the date of the form while on the plane, presumably redeploying from Iraq. She did not lose consciousness at any time, but had complaints of nausea earlier and current complaints of headache and pressure over the apex of the skill on the right side. She had a normal neurological examination and normal electrocardiogram (EKG) and was released without limitation. 13. A Physical Exam Checklist shows the applicant underwent a periodic health assessment on 11 March 2010 and there is a handwritten note next to the medical provider (last exam station) section of the form, stating “no-go; P-3 [physical profile rating of “3”) for L [lower extremities].” 14. The applicant’s DD Form 214 shows she returned from Kuwait/Iraq on 14 March 2010. 15. A DA Form 2173, signed by the attending physician assistant during demobilization on 16 March 2010, shows the applicant was seen on an outpatient basis at the Fort McCoy, WI Troop Medical Clinic (TMC) on an unspecified date for a left knee injury. The details of the accident or history of disease show the applicant reported a left knee injury while training at Fort McCoy during pre-mobilization. Now at demobilization she continues to have intermittent left knee pain with running. Section II (To be Completed by Unit Commander or Unit Adviser) is not filled out or signed by an official from her unit. 16. A second DA Form 2173, signed by the attending physician assistant during demobilization on 16 March 2010, shows the applicant was seen on an outpatient basis at the TMC in Ballad, Iraq on an unspecified day in March 2010 for a head injury. The details of the accident or history of disease show the applicant reported blunt trauma to her head from an M-4. No loss of consciousness at the time of the injury, but she saw stars and had three fainting episodes after the incident. At demobilization cite she has intermittent headaches and occasional dizziness. Section II is not filled out or signed by an official from her unit. 17. Her DD Form 214 shows the applicant was honorably released from active duty post-deployment on 5 April 2010, after 11 months and 5 days of net active service, due the completion of required active service and transferred back to the KYARNG. 18. Medical documents from September 2010 show the following: * the applicant was seen in Physical Medicine and Physical Therapy on 15 September 2010; she needed to wear a left knee sleeve with running and physical activities due to patellar discomfort * A VA Work Excuse shows the applicant was seen in orthopedics on * 23 September 2010 and may return to work on 24 September 2010 with the restriction of no running for 4 weeks 19. A Lexington VA Medical Center (VAMC), Orthopedic Surgery Clinic Nursing note, dated 1 February 2011 shows, the applicant received corticosteroids in her knee for osteoarthritis/inflammation of the knee joint. She was to decrease daily running, resume activity and weight-bearing as tolerated, and increase swimming, biking, and elliptical. A VA Work Excuse, likewise dated 1 February 2011, shows she was seen in the orthopedics clinic on the date of the form and was able return to work on 2 February 2011. She was to resume physical therapy for quad strengthening. 20. A DD Form 214 shows the applicant was ordered to active duty in support of Operation New Dawn on 24 August 2011 and served in Kuwait/Iraq beginning on 1 November 2011. 21. An SF 600 shows the applicant was seen in theater on 22 November 2011 at the 40th Combat Aviation Brigade Clinic for a musculoskeletal examination of her knee. She reported complaints of right knee pain since February 2009 and that she had been diagnosed with cartilage damage and osteoarthritis. She received steroid injections, physical therapy and had two LODs completed for her right knee. She uses Tylenol and Motrin for pain. There was no knee swelling, discoloration, crepitus, numbness or tingling. She was diagnosed with left knee patellofemoral syndrome and was given a limited physical profile of no running, jumping, and climbing for 2 weeks. 22. A DA Form 3349 shows on 22 November 2011, the applicant was given a temporary physical profile rating of “2” for lower extremities due to left knee patellofemoral syndrome and chondromalacia with an expiration date of 20 February 2012. She was restricted from running 2 miles for the Army Physical Fitness Test (APFT), but was okayed for alternate events. She was to use a knee brace at all times for stability and to walk or run at her own pace. 23. An SF 600 shows the applicant was seen at the Buehring TMC on 13 February 2012 for right knee and left hip pain elicited by motion. Her chief complaint was knee pain. She was diagnosed with left hip sprain hamstring insertion. She had a history of left hip pain an d was unable to rest on the affected side with pain on adduction and in external rotation of the hip. Her temporary physical profile of no running was extended to 13 May 2012. The injury/illness is listed as not work related; not battle related. 24. A DA Form 3349 shows on 13 February 2012, the applicant was given a temporary physical profile rating of “2” for lower extremities due to left knee patellofemoral syndrome and chondromalacia with an expiration date of 21 May 2012. She was restricted from running 2 miles for the APFT, but was okayed for alternate events. She was to use a knee brace for stability and walk/run at her own pace. 25. A DA Form 3349 shows on 21 April 2012, the applicant was given a permanent physical profile rating of “2” for lower extremities due to left knee patellofemoral syndrome and chondromalacia. She was restricted from running 2 miles for the APFT, but was okayed for alternate events. She was to use a knee brace for stability and walk/run at her own pace. 26. An SF 600 shows the applicant was seen at the Buehring TMC on 30 May 2012 for continuing treatment for limb pain. She was released without limitations and was to follow up as needed. 27. Her DD Form 214 shows the applicant completed her service in Kuwait/Iraq on 9 June 2012 and was honorably released from active duty on 13 July 2012, after 10 months, and 20 days of net active service, due to the completion of required active service and transferred back to the KYARNG. 28. The applicant provided numerous NCOERS, showing the following: a. The NCOER covering the period from 6 June 2011 through 5 June 2012 shows she passed her APFT on 18 May 2012 and was commended for her role in the successful mission and handoff of the Camp Taji TMC, Iraq. She was not rated below “success” in any category and was rated “excellence” in three categories. b. The NCOER covering the period from 6 June 2012 through 5 June 2013 shows she passed her APFT on 18 May 2013, enrolled in a Master of Arts program, served admirably as the acting section chief, and was not rated below “success” in any category. c. The NCOER covering the period from 6 June 2013 through 5 June 2014 shows she was unable to participate in the most recent record APFT due to the hospitalization of her child, completed her studies to become a Certified Chemical Dependency Counselor, and was not rated below “success” in any category. d. The NCOER covering the period from 6 June 2014 through 5 June 2015 shows she passed her APFT on 22 January 2015, graduated with a Master of Arts degree in psychology, and was not rated below “success” in any category. 29. Boone National Guard Center Orders 029-026, dated 29 January 2015, ordered the applicant to active duty at Camp Shelby, MS for attendance at the Warrior Leader Course from 6 February 2015 through 28 February 2015, in lieu of Annual Training. 30. A Forrest General Hospital Emergency Room Report, dated 21 February 2015 shows the applicant was seen for the chief complaint of passing out. The history of present illness shows she was doing drill in the morning, hiking, and carrying a pack when she started to feel really week and then just kind of collapsed. She has a severe headache and really does not remember what happened. She does not know how long she was out. She had never passed out before and did not have any palpitations or sense of tachycardia. A CT scan of the head showed no hemorrhage, infarct, or fractures. She was discharged to bedrest for the next day and quarters for 2 days. 31. Boone National Guard Center Permanent Orders 101-016, dated 10 April 2016 order the applicant as a member of her ARNG unit to full Time National Guard Duty – Operational Support (FTNGD-OS) for the period from 4 June 2016 through 16 June 2016 with duty in Portland, OR, Warrenton, OR, Shelton, WA, and Tacoma, WA. 32. Neither medical or unit documentation pertaining to the shoulder injury the applicant states she sustained during this period of FTNGD-OS in June 2016, is in her available records for review. 33. The applicant’s NCOER covering the period from 6 June 2015 through 6 June 2016 shows she passed her APFT on 8 August 2015, persevered through training despite injuring her ankle, she did not allow her physical injury to impact her duty obligations, and was rating as “met standard” in all categories. 34. A Physical Profile Record shows that in addition to her permanent profile rating of “2” for her knee, the applicant was given a temporary physical profile for a right shoulder injury/pain on 19 May 2017. She was anticipated to be available to take the APFT on 19 October 2017. She was given a lifting/carrying restriction of 10 pounds and provided with modified exercises she could perform. 35. The applicant’s NCOER covering the period from 6 June 2016 through 6 June 2017 shows a physical profile due to injury with ongoing therapy prevented her from taking a record APFT, she consistently led from the front, and was rated “met standard” in all categories. 36. A Premier Orthopedic and Sports Medicine report, dated 23 October 2017, shows the applicant was seen on the date of the report for complaints of right shoulder pain. She stated she originally injured her shoulder in Iraq approximately 5 years ago carrying heavy objects. The pain has gotten worse over time. The impression was of right shoulder pain with labral tear. The plan was to proceed with a right shoulder scope for debridement and biceps tonotopy. 37. A Saint Joseph London Operative Report, dated 2 November 2017, shows the applicant’s pre and post-operative diagnoses were right superior labral tear. On the date of the form she underwent right open sub-pectoral biceps tenodesis and right shoulder arthroscopy with limited debridement. The post-operative plan was no lifting of the right upper extremity and use of a sling at all times for approximately 2 weeks with follow-up in 1 week for reevaluation. 38. A Saint Joseph London Radiology Report, dated 3 February 2018, shows the applicant underwent multiple computed tomography (CT) scans on the date of the form after the applicant fell that morning resulting in arm numbness and tingling. The CT scan of the cervical spine without contrast showed no acute fracture of the cervical spine and multilevel degenerative disc disease. The CT scan of the abdomen and pelvis showed no evidence of acute intra-abdominal or intra-pelvic abnormality. 39. In a self-authored letter addressed to whom it may concern, dated 25 April 2018, the applicant stated she was enrolled in the Basic Leadership Course at Camp Shelby in February 2015 which she was unable to complete at the time. While conducting land navigation, she passed out on numerous occasions. She was briefly treated at Camp Shelby then transported to the Forrest General Hospital in Hattiesburg, MS and awoke during a lumbar puncture. Since then, she has had back spasms and tingling in her toes and the bottom of her feet. She was given an LOD that was initiated at Camp Shelby, which was to be completed by her unit and was also given a copy of the major incident report, which she passed on to her unit, but that paperwork was lost by her unit and was not uploaded in iPERMS or any other database. She was requesting copies of these documents. 40. A Physical Profile Record shows that in addition to her permanent physical profile rating of “2” for her knee, the applicant was given a temporary profile for her right shoulder injury/pain on 21 May 2018 and was given modified activities she could perform. 41. A Physical Profile Record shows that in addition to her permanent physical profile rating of “2” for her knee, the applicant was given a permanent physical profile rating of “3” for upper extremities due to her right shoulder injury/pain on 29 May 2018. 42. The applicant’s NCOER covering the period from 6 June 2017 through 5 June 2018 shows a physical profile due to injury with ongoing therapy prevented her from taking a record APFT, she was not recommended for promotion at the time, and was rated “met standard” in all categories. 43. A KYARNG memorandum, dated 8 June 2018, shows the following: a. The applicant was notified of her medical disqualification. She was informed a review of her Army medical records indicated she no longer met the Army medical standards for retention in accordance with Army Regulation 40-501 (Standards of Medical Fitness) based on her current medical condition of right shoulder injury/pain. b. She was advised she must elect either discharge from the ARNG as a Reserve of the Army or choose an appeal through the non-duty related PEB for a retention ruling only. If she chose discharge from the ARNG and as a Reserve of the Army, she would receive an Honorable Discharge Certificate. If she elected non-duty related PEB retention ruling only, she must submit current pertinent medical documentation to support her request. 44. The applicant signed a memorandum on 10 June 2018, indicating her intent. As she was physically disqualified for further retention in the ARNG, she elected to undergo a non-duty related PEB for retention ruling. 45. The applicant provided email correspondence from June 2018, between herself and members of her unit stating she would like to appear before the PEB because she believes her shoulder injury is duty related. She first injured her shoulder in AIT, then during the Oregon/Washington AT, and once more on the morning of 3 February 2018 while falling on her way to drill. She argues did not receive LODs for these injuries as she should have. She was not arguing she should remain in the ARNG, as she knew she could not fulfill the requirements of remaining in the ARNG, but rather she was arguing her injury was duty-related instead of non-duty related. 46. A Premier Orthopedic and Sports Medicine report, dated 13 June 2018, shows the applicant was seen at the clinic for reevaluation of her right shoulder. She developed right rotator cuff tendinitis after open sub-pectoral biceps tenodesis in November 2017. She has improved significantly and may continue conservative measures, such as home exercises and pain cream. 47. A KYARNG memorandum, dated 8 August 2018, shows the applicant was seen at Boone National Guard Clinic at the request of her unit and was found to be not fit for duty due to right shoulder injury/pain. She was issued a permanent physical profile rating of “3” for her shoulder and “2” for her knee and was recommended for separation. 48. A DA Form 199 shows the following: a. An IPEB convened on 28 August 2018 and found the applicant physically unfit and recommended her disposition be according to Reserve Component regulations as the IPEB was adjudicated as a non-duty related case. b. The applicant’s unfitting disability was right shoulder injury/pain with a rating of 0 percent. The onset of this injury occurred in 2017 while the applicant was in the Continental U.S. She was unfit because the physical limitations associated with this condition made her unable to reasonably perform duties required by her MOS and multiple functional activities. c. On 30 October 2018, the applicant signed the form indicating she did not concur with the findings and recommendations and demanded a formal hearing. She attached her written appeal, requested personal appearance, and requested regularly appointed counsel. 49. A DA Form 2823, dated 30 October 2018, shows the applicant made the following sworn statement: a. She initially injured her right shoulder while in AIT in 2008. She was seen at both the TMC at Fort Sam Houston and also at BAMC. Her shoulder did eventually heal without surgical intervention, but she reinjured it on numerous occasions, to include while deployed to Iraq/Kuwait in 2010-2011 and while on orders for AT in OR and WA in June 2016. b. She has never been able to provide an exact event that caused specific injury to her shoulder, but each injury was preceded by a higher level of lifting and weight bearing, to include lifting weight over her shoulder and head. Her right shoulder always seemed to heal, but it then seemed to quickly get worse afterward. She has undergone steroid injections, physical therapy and surgery in December 2017 for a labral tear. c. Her most recent injury to her shoulder occurred on 3 February 2018 on a scheduled drill day when she slipped on ice going to her car, re-aggravating the shoulder injury. She was advised she would be able to submit medical documentation to her unit, but was later advised by her company commander that an LOD could not be completed due to her absence. She continues to have right shoulder pain and wishes to appeal the IPEB findings. 50. A memorandum from the applicant’s MEB Counsel, dated 31 October 2018, served as her appeal and rebuttal to the non-duty related IPEB Proceedings dated 28 August 2018. The complete memorandum has been provided to the Board for review. It states in pertinent part the following: a. The applicant requests that the Board find her right shoulder disability is duty- related and that her case be referred to a Medical Evaluation Board (MEB) for complete analysis and evaluation and that it generate a new DA Form 199 reflecting this decision. b. It is clear the applicant’s right shoulder disorder prevents duty performance in its current state and is unfitting. The issue before the Board is whether or not the disability is duty-related, and if so, should her case be referred to an MEB for evaluation and assessment. A legitimate and documented argument can be made that the onset of her right shoulder disorder was in 2008 while in AIT. Her condition improved over time and she was able to continue service; however, her June 2016 injury to her right shoulder while on annual training could be found as constituting the onset which ultimately led to shoulder surgery in November 2017. She progressed well following the surgery, but her 3 February 2018 slip and fall on the ice while enroute to drill re-injured the shoulder leaving her unfit. Under these circumstances, her shoulder injury should be found in the LOD based on a preponderance of the evidence. c. Army Regulation 635-40 provides that while it is not intended that PEBs act as hearing authorities for Soldier appeals of LOD determinations, the Soldier may present evidence of error concerning an LOD finding and it provides that the PEB has the authority to return a non-duty related case for re-referral under the Integrated Disability Evaluation System (IDES) process when there is evidence the condition was incurred in or aggravated in the LOD. 51. A National Capital Region PEB memorandum, dated 19 November 2018, informed the applicant her non-concurrence to the IPEB was received and acknowledged her demand for a formal hearing, with regularly appointed counsel and her personal appearance. She was informed that consistent with her election, she would be scheduled for a formal hearing. 52. A National Capital Region PEB memorandum, dated 20 November 2018, informed the applicant she was scheduled for a formal PEB on 10 January 2019. a. She was also informed that her case was submitted to the PEB as a Reserve component non-duty related case. The determination as to whether a case is forwarded to the PEB as a “non-duty related” case rests with the appropriate Reserve component commander. She was not permitted to challenge that determination before the PEB. As a “non-duty related” case, the PEB may not address the issues of LOD, disability rating, or eligibility for compensation. The only determination the PEB can make in her case is whether she is fit or unfit for continued service. b. Since she disagreed with the IPEB finding of unfitness, it is presumed she believes she is fit to perform her military duties. Fit versus unfit is the only decision the PEB is authorized to make in her case. As a “non-duty related” case, travel costs, lodging, and other expenses associated with her formal hearing would not be paid or reimbursed by the Government. c. Since she requested to be represented by the regularly appointed military counsel, her case has been assigned to the Office of Soldiers’ PEB Counsel, who will contact her to prepare for the upcoming hearing. She was informed of the importance of making contact with her counsel to discuss her case. 53. A DA Form 199-1 (Formal PEB Proceedings) shows the following: a. A formal PEB convened on 10 January 2019 and found the applicant physically unfit and recommended her disposition be according to Reserve Component regulations as the PEB was adjudicated as a non-duty related case. b. The applicant’s unfitting disability was right shoulder injury/pain. The onset of this injury occurred in 2017 while the applicant was in the Continental U.S. She was unfit because the physical limitations associated with this condition made her unable to reasonably perform duties required by her MOS and multiple functional activities. c. The applicant elected to appear at the formal proceedings and was represented by regularly appointed counsel. d. The applicant requested that the formal PEB find her right shoulder injury/pain, left knee pain, and vision/eye conditions are unfitting and compensable. Based on her testimony, further review of subsequent medical evidence and a complete review of the original case file, the formal PEB determined the preponderance of medical evidence did not support finding the right shoulder, left knee, and eye conditions were permanently aggravated by military service or incurred in the LOD. The formal PEB did not find the left knee and eye conditions unfitting. The applicant has no approved LOD in the case file. The PEB found the applicant was unfit for duty for her right shoulder injury/pain and found no changes to the original decision and that her disposition be referral for case disposition under the Reserve Component regulations. 54. A memorandum from the applicant’s PEB Counsel, dated 9 February 2019, served as her appeal and rebuttal to the non-duty related formal PEB Proceedings dated 10 January 2019. It states the applicant reiterates her contention that her unfitting shoulder condition is duty-related and that her knee condition is both duty-related and unfitting. a. As new evidence she provided records from her 2017 shoulder surgery and post- operative visits wherein the injury is attributed to an incident during her 2012 Kuwait deployment. She also provides a 2010 Periodic Health Assessment which noted she had a “P3” for lower extremities and Physical Profiles showing she remained on profile for her knee. b. She also asserts that her diagnosed vision condition is both duty-related and unfitting because it resulted from the use of Flexeril prescribed for her shoulder condition. Her treating provider clearly concluded in June 2018 that her vision diagnosis was “Flexeril-induced glaucoma.” 55. A U.S. Army Physical Disability Agency (APDA) memorandum, dated 30 May 2019, provided the Adjutant General of Kentucky a copy of the PEB action for the applicant’s non-duty related case and advised the outcome was a determination of unfitness for duty. 56. An APDA memorandum, dated 30 May 2019, informed the applicant they noted her disagreement with the findings of the PEB and reviewed her entire case. The APDA’s conclusion is that her case was properly adjudicated by the PEB, which correctly applied the rules that govern the Physical Disability Evaluation System (PDES) in making its determination. The findings and recommendations of the PEB are supported by substantial evidence and are therefore affirmed. The issued in her appeal were responded to by the PEB in its 26 February 2019 memorandum and the APDA concurs with the response provided by the PEB. 57. The applicant has not provided a copy of the PEB rebuttal response memorandum dated 26 February 2019 and it is not in her available records for review. 58. Boone National Guard Center Orders 182-859, dated 1 July 2019 honorably discharged the applicant from the ARNG and as a Reserve of the Army under the provisions of National Guard Regulation 600-200 (Enlisted Personnel Management), paragraph 6-35l, due to medical disqualification. 59. The applicant’s NGB Form 22 shows she was honorably discharged from the KYARNG on 1 July 2019 after 11 years, 10 months, and 15 days of net service under the provisions of National Guard Regulation 600-200, paragraph 6-35l, due to being medically unfit for retention per Army Regulation 40-501. 60. A VA Rating Decision, dated 18 November 2019 and letter dated 20 November 2019 show the applicant was granted a service-connected rating of 20 percent for right shoulder tendonitis effective 1 August 2019, with a combined service-connected rating of 40 percent effective that same date, which is an increase from a combined rating of 20 percent effective 14 July 2012. 61. The Army rates only conditions determined to be physically unfitting at the time of discharge, which disqualify the Soldier from further military service. The Army disability rating is to compensate the individual for the loss of a military career. The VA does not have authority or responsibility for determining physical fitness for military service. The VA may compensate the individual for loss of civilian employability. 62. Title 38, U.S. Code, Sections 1110 and 1131, permit 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 an error or injustice on the part of the Army. 63. Title 38, CFR, Part IV is the VA’s schedule for rating disabilities. The VA awards disability ratings to veterans for service-connected conditions, including those conditions detected after discharge. As a result, the VA, operating under different policies, may award a disability rating where the Army did not find the member to be unfit to perform his duties. Unlike the Army, the VA can evaluate a veteran throughout his or her lifetime, adjusting the percentage of disability based upon that agency's examinations. 64. MEDICAL REVIEW: a. The Army Review Board Agency (ARBA) Medical Advisor reviewed the supporting documents and the applicant's records in the Interactive Personnel Electronic Records Management System (iPERMS), the Armed Forces Health Longitudinal Technology Application (AHLTA), the Health Artifacts Image Management Solutions (HAIMS) and in the VA's Joint Legacy Viewer (JLV). The applicant requested a review of her medical records and physical disability rating. She also had multiple LOD requests the most significance of which she stated were for the right shoulder, head and knee injuries. She also mentioned back, ankle and vision issues. This case involved several conditions as well as secondary conditions. The ARBA reviewer tried to organize the large volume of medical evidence in a meaningful manner. b. JLV search showed the VA service connected the following disabilities at 80% total combined for: Major Depressive Disorder (50%); Paralysis of Upper Radicular Nerve Group (20%); Paralysis of Upper Radicular Nerve Group (20%); Limited motion of Arm (20%); Cervical Spine Intervertebral Disc Syndrome (10%); Lumbar Spine Intervertebral Disc Syndrome (10%): Paralysis of Sciatic Nerve Group (10%); Paralysis of Sciatic Nerve Group (10%); Knee Condition (10%); Limited Flexion of Knee (10%); Limited Motion of Ankle (10%); Limited Extension of Thigh (10%); Limited Flexion of Thigh (0%); and Thigh Condition (0%). c. The case was referred to the PEB as non-duty related. Eventually, the applicant’s Right Shoulder Injury/Pain condition was found unfitting for continued military service, by a Formal PEB convened 10Jan2019. In addition, the PEB noted that the onset was in 2017. The following are the available treatment notes for the right shoulder condition and profile information. (1) 26Aug2008 Brooke Army ER visit for right arm pain of severity 3/10 and duration of 3-4 months, that radiated to the shoulder and back. There was no known injury. Right shoulder films showed no obvious fracture or dislocation identified. (2) 2015 Camp Shelby LOD was started but not completed. (3) The applicant wrote in her 19Aug2020 statement: “I injured my shoulder during AT in Oregon/Washington in 2016, leading to separation.” The reviewer did not find treatment records related to a 2016 injury. (4) 13Apr2017 MRI showed right shoulder Distal Tendinopathy of Right Suprapinatus Tendon (Rotator Cuff) (5) 05Apr2017 Grace Health. Prescription to avoid push-ups pending MRI results (6) 03May2017 Grace Health. Prescription to avoid activities involving lifting, pushing, pulling of right shoulder (7) 15Oct2017 Periodic Health Assessment. She reported seeing specialists for her right shoulder, and was given a temporary profile. (8) 23Oct2017 Premier Orthopedic and Sports Medicine. She complained of right shoulder pain. She reported that she originally injured the shoulder in Kuwait approximately 5 years earlier carrying heavy objects. She said the pain comes and goes. There was no treatment record found for the reported injury. (9) 02Nov2017 Saint Joseph London. The applicant underwent Open Subpectoral Biceps Tenodesis surgery to repair her Right Superior Labral Tear (10) 20Dec2017 Premier Orthopedic and Sports Medicine. Follow up visit after her shoulder surgery: The applicant indicated she stopped her physical therapy because she developed medication induced glaucoma. As a result, she noticed her right shoulder had started to become stiff. (11) 29Dec2017 date of slip and fall injury after which she had increased pain (12) 03Feb2018 Saint Joseph London (Kentucky) ER note. She fell on the right side of her body that morning. In her personal statement, she stated that she slipped on ice and fell carrying her gear/uniform to the car to leave for drill. She went to the ER and not to drill. Her drill was designated as split training. (13) 05Feb2018 Premier Orthopedics and Sports Medicine. (The day after the 03Feb2018 fall, there was no mention of the more recent reported fall). “The patient reports falling on December 29, 2017. She has had increased shoulder pain since that time. … She states that she was doing decently well prior to her fall. Her pain had improved compared to her preoperative status; however, she has had decreased use of the right shoulder after the fall. She has difficulty raising her arm over her head. The patient does not report feeling a pop. She is unsure of how she exactly fell”. (14) 12Apr2018 PT PROS Physical Therapy & Sports Centers Re-Evaluation. She had attended 11 treatment sessions of physical therapy since the last evaluation. (15) 13Jun2018 Premier Orthopedics and Sports Medicine note. The specialist opined that she had developed right rotator cuff tendinitis injury after her November 2017 surgery. (16) Shoulder Injury/Pain (Right) temporary 60day profile to expire 06Jun2018 functional activity restrictions: unable to carry and fire assigned weapon, unable to move fighting load (48#), unable to construct a fighting position, unable to perform timed pushups, unable to perform timed sit-ups, unable to perform aerobic swimming. (17) This condition did not meet retention standards. The VA has service connected Right Shoulder Tendonitis at 20%. (18) Recommend: Right Shoulder Tendonitis, not in line of duty. (19) Rationale. She was seen for right shoulder pain in August 2008. The shoulder films were negative. Treatment records showed that she was not seen again for shoulder issues until 2017. During those 2017 visits and beyond, she reported right shoulder re-injuries in 2010 and 2011 in Iraq/Kuwait (30Oct2018 statement on DA Form 2823); 2012 Iraq and June 2016 during AT in Oregon (19Aug2020 personal statement). The applicant also stated that she was seen in 2012 for her right shoulder. However, that 30Mar2012 in-theatre note, indicated she was seen for (new) limb pain without any other details. The specific limb was not specified. There was no injury; and no exam findings. No films were ordered and there was no follow up. After the episode of shoulder symptoms in 2008, there was no documented medical evidence of duty related right shoulder injury or exacerbation. She completed 2 deployments without any in-theatre visits for right shoulder issues. After 2008, she wasn’t seen again for right shoulder pain until April 2017 (5 years after her last deployment); and she was seen by non military orthopedic specialists; and while she was not on active orders. After that point, there was no compelling medical evidence that her right shoulder condition was aggravated by a duty related injury or event. d. Headaches/Cervicalgia. The applicant stated that she had a head injury in 2010 for which a LOD was not completed. (1) Head Injury. (a) 09Mar2010 332ND EMDG (FM6943) Clinic note. She was hit in the head with a swinging rifle on the plane. There was no loss of consciousness. She initially had nausea but it resolved prior to the visit. She complained of headache and pressure sensation over the apex of her skull. Her neurologic exam was normal. She had an abrasion over the left forehead. (b) 17Mar2010 Ireland ACH visit for DEMOB. She complained of a mild headache. Neurologic exam was normal. She was cleared. (c) 01Sep2011 TMC-14 Clinic. She reported dizziness x 2days in the morning and intermittent ear pain. Ear exam was normal. Diagnosis: Vertigo. (d) 21Feb2015 Forrest General Hospital note. The applicant had been participating in drill that morning, hiking with a pack. She fell and was found unconscious. She reported headache and neck pain. (e) 03Apr2015 Neurology visit for EEG. There was no report of headaches. (f) 27May2015 Neurology follow up after Feb2015 syncope. She was found unconscious after climbing on duty. The neurologist annotated that she had a concussion. She had some amnesia surrounding the event. There was no mention of headaches. (g) 03Feb2017 Primary Care Note. Posttraumatic Headache appeared in the problem list. (h) 20Jun2018 was the first time a headache specific medication was prescribed (sumatriptan). She had mild to moderate and sometimes severe headaches that improved with the use of sumatriptan. (i) 28Nov2018 UK KY Neuroscience Institute. It was noted that she was not taking preventive headache medicine yet. Diagnosis: Chronic Migraines. (j) This condition was not service connected by the VA at this time. Evidence was insufficient to support that this condition failed retention standards. (k) Recommend: Concussion, in line of duty. (l) Rationale. She likely sustained a mild concussion in March 2010 because she had a head injury with associated nausea and prolonged headache. She also had vertigo and a syncopal episodes later. She also may have sustained head injury when she fell in February 2015, while on active orders. She developed tension and migraine headaches later. The UpToDate™ literature search was not clear on the time frames on how long after the event, symptoms can develop, or how long after they may persist. The ARBA reviewer did not find a comprehensive TBI exam. (2) Syncope. 29Jan2015 Boone National Guard Center ORDERS 029-026 report time 06Feb2015 to 28Feb2015. (a) 21Feb2015 Forrest General Hospital note. The applicant had been participating in drill that morning, hiking with a pack. She was found unconsciousness. No seizure activity was observed. She reported a headache and neck pain. Exam showed pain with neck flexion. The labs, CT of head and EKG did not yield an underlying condition. Diagnosis: Syncope and Tension Headache. The c-spine films were negative. (b) 14Apr2015 Neurology Consult. She was seen in follow up by neurologist. The follow up MRI was also within normal limits. The EEG showed no epileptiform activity (no epilepsy). The neurologist diagnosed: Possible Seizure. She was instructed to return if any other episodes. The applicant stated (25Apr2018 statement) “While conducting land navigation, I passed out on numerous occasions”. The reviewer found only the 21Feb2015 event. It was also noted that the neurologist wrote ‘concussion’ in his note. However, the original note detailed that there was “no head trauma”. The review revealed that the applicant had been seen 1 and 2 days prior for dizziness, dehydration, and diarrhea. (c)Recommend: Syncopal Episode with Headache 21Feb2015, in line of duty. No further episodes. Resolved. (3) Lumbar Puncture Headache. (a) 06Nov2018 UK KY Neuroscience Institute note. The applicant had a lumbar puncture (LP) procedure because of a history of papilledema; however, the note indicated that papilledema was absent. The LP pressure and other results were normal. Papilledema is increased pressure in or around the brain causes the part of the optic nerve inside the eye to swell. (b) 09Nov2018 Kentucky One Health Saint Joseph London note. She was seen for a persistent headache after the LP, which is not uncommon. She was sensitive to light and noise; and had accompanying, nausea and neck pain. She was unable to tolerate a vertical position. Her post LP headache was treated with a blood patch, and hydration. Condition RESOLVED. e. Neck (1) 21Feb2015 VA Primary Care note. She first reported neck pain after the syncopal episode. C-spine films were negative. She had pain with neck flexion. (2) 25Feb2015 VA Primary Care note. She still was reporting neck pain. (3) 10Jan2018 UK Ophthalmology. She had pain behind her eyes, headaches and pain in back of her head. (4) 09Nov2018 Saint Joseph London Hospital ER visit for headache and posterior neck pain. (5) 28Nov2018 UK Health Care Neuroscience Institute. Visit for headaches. Diagnosis: Cervico-occipital neuralgia of left side. (6) 05Dec2018 Baptist Health My Chart. A cervical spine MRI was ordered for chronic neck pain. Impression: Degenerative disc change at C5-C6 and C6-C7 with loss of disc height, disc desiccation and mild broad-based disc bulge not impinging upon the cervical cord. (7) The VA rated Cervical Spine Intervertebral Disc Syndrome (IVDS) at 10%. Evidence was insufficient to support that this condition failed retention standards. (8) Recommend: Cervical IVDS in line of duty. (9) Rationale, the applicant reported neck pain for several days after the fall in 2015. 3 years later degenerative changes were present. f. Back (1) 12Mar2012 Buehring Theatre Clinic note. She presented with chronic mid back pain that radiated when it was exacerbated, to the front along the sternal border (2/10). The note didn’t mention when the pain started or method of injury. No recent injury was reported. The pain started in mid back as a tight feeling that was worse with activity and with laying down at night on cots. (2) 13Apr2012 Buehring Theatre Clinic note. Refill on Ibuprofen for back pain. (3) 12Jun2012 CA SRP Pre and Post Deployment Physical. There was no mention of back pain. (4) 27Sept2015 Baptist Health Corbin Emergency Room. She reported a fall that day that caused back pain, left hip, and left thigh pain. It was recorded that she slipped and fell at home. Back Exam: Revealed moderate tenderness, swelling, and spasm in the mid and lower back. There was decreased range of motion in all spheres. Lumbar spine film was normal. (5) 12May2017 note. Seen for low back pain radiating to right lower extremity. She was diagnosed with Acute Low Back with Sciatic, Sciatica Laterality Unspecified. She was given Flexeril, Indomethacin, and Prednisone. MRI showed Impression: L5/S1 disc dessication with small posterior disc bulge. (6) The VA rated Thoracolumbar Spine Intervertebral Disc Syndrome at 10%. Evidence was insufficient to support that this condition failed retention standards. (7) Recommend: Thoracolumbar Degenerative Disc Disease, not in line of duty. (8) Rationale: At her first presentation to a military facility for back pain, she already had a chronic history of back pain with unknown onset and etiology. There had been no duty related back injury. The 2012 episode of back pain was resolved by the time she was seen for the post deployment physical. g. Left Knee. The applicant reported knee injury during pre-mob 2009, and “numerous aggravations” while on Mobilization (1) 27Mar2008 TMC Physical Therapy note. In the 6th week of BCT, she was seen reporting pain in both knees for 5 weeks. There was no injury. She was given a no jump/no march profile for both knees with expiration 04Apr2008. (2) 26Aug2008 Brooke Army ER note. She complained of left knee "slipping while walking" for past week with no recent injury. She denied left knee pain. (3) 16Jan2009 ORDERS 016-037 indicated TDY period from 02Feb2009 to 26Feb2009 at Ft McCOY (4) 13May2009 Hattiesburg Clinic. Left knee MRI showed degenerative changes in the patellofemoral compartment. There was a osteochondral defect with associated bone bruising over the anterior lateral femoral condyle. (5) 14May2009 Camp Shelby TMC. She reported knee injury while training in February 2009. She stated that she was seen in ER. She wears a brace, left knee buckles when she does the 2 mile run, but she was able to complete the run. She denied pain at the time. She hadn't had a PT test since the knee injury. (6) 14May2009 Individual Sick Slip for Left Knee Pain: No running, no jumping, no marching, no high impact activities x 1 week. (7) 21May2009 Camp Shelby. She stated she was able to resume training. (8) 22Oct2009 550th Prosperity Clinic. She was seen for exacerbation of left knee pain, for 3 hours, that started after running. She stated that she initially injured the left knee February 2009 when it twisted due to falling off a ladder. (9) 16Mar2010 DA Form 2173 (incomplete) Left knee injury while training at Ft McCoy at premobilization. At demobilization, she continued to have pain. (10) 24Sep2010. No running work excuse was given. (11) 01Feb2011 Ortho Surgery Clinic note. A work excuse to return to work with restrictions to decrease running. Bike, swim, and elliptical activities were okay. (12) 22Nov2011 visit for Left Patellofemoral Syndrome indicated that she had an MRI that showed some chondromalacia. Knee pain for 2 years, she may benefit from arthroscopy to assess chondral surfaces and other structures (13) Left Knee Patellofemoral Syndrome and chondromalacia temporary profile set to expire 20Feb2012. The 2 mile run was prohibited. (14) 12Mar2012 Buehring Theatre Clinic. She presented with chronic left knee pain (15) She had a permanent L2 physical profile dated 21Apr2012 for Patellofemoral Syndrome and Chondromalacla with no 2-mile run. It was okay to use a brace. All functional activities were okay. (16) 19Oct2012 Knee Conditions C&P exam. Left Knee: Flexion to 120 degrees (140 degrees is normal). Knee extension was normal. There was no objective evidence of painful motion. Knee strength was normal. Testing showed no instability of the knee joint. There was crepitus (sound of cartilage rubbing on the knee joint). No evidence or history of subluxation and no suspected meniscal issues. Occasionally wore a knee brace. Diagnoses: Left Knee Patellofemoral Syndrome with Degenerative Changes in the Patellofemoral Compartment. (17) 27Sept2015 Baptist Health Corbin Emergency Room note. She reported a slip and fall accident that occurred that day at home, that caused back pain, left hip, and left thigh pain. Although the left knee film showed proximal fibula non- displaced fracture, the ARBA reviewer noted that the diagnosis was Left Knee Contusion. The non-displaced fracture was not acknowledged in the note. However, the limb was splinted and she was given crutches. (18) 28Sep2015 Baptist Regional Medical Center note documented the history: While walking down a heel to retrieve a football, she fell directly onto her knees and slid about 2 feet down the hill. Diagnosis: Left knee contusion. (19) 06Oct2015 Kentucky One Health (KOH) Ortho Associates note. The left knee MRI showed acute tears of medial and lateral gastrocnemius tendons without retraction; proximate fibula trabecular microfracture; small to moderate joint space effusion; menisci and cruciate ligaments were intact. (20) 21Oct2015 KOH Ortho Associates. Visit for knee lidocaine injection. (21) 21Oct2015 KOH Physical Therapy. 8 week prescription for seated duties only. (22) 11Nov2015 KOH note. She reported feeling that something in her knee was sliding. MRI of her knee did not show an ACL injury. Lachman test showed slight laxity when compared to the contralateral side. (23) 11Nov2015 KOH. The restrictions given were no squatting, running, hill climbing, driving tactical vehicles, or lifting greater than 50 pounds. (24) 11Nov2015 Physical Therapy &Sports Centers Initial Evaluation. She was employed fulltime and was able to perform all duties. She reported difficulty walking and difficulty performing guard duty. Her rehab potential was good. She was to be seen 2x/week for 8 weeks for a total of 16 visits. (25) 01Jan2016 Physical Therapy Discharge Summary. She was discharged from the program. She had attended 4 of the 16 sessions. (26) 30Sep2016 Physical Therapy & Sports Centers Initial Evaluation. She re- engaged with physical therapy because of complaints of hip/knee pain with decreased lower extremity strength, she expressed difficulty performing National Guard duty, decreased flexibility, and difficulty walking. An abnormal gait pattern was noted. Physical therapy was advised again: 16 in-person visits (2x/week for 8 weeks). Rehab potential was good. (27) 15Oct2016 permanent L2 physical profile for Knee Pain/Injury (Left) (28) 27Oct2016 Physical Therapy Discharge Summary. She was discharged from the program. She had only attended the initial evaluation session. She was instructed in a home exercise program, no further in-person therapy was planned. She was employed (civilian) full time and was able to perform all duties. No work restrictions were listed. She reported the commitment of National Guard training several times a year and had no limitations with this. (29) Diagnoses: Pain ln left knee; Pain in left hip; Patellofemoral disorders, left knee; Other instability, right knee; Stiffness of left knee, not elsewhere classified. (30) Left Knee Patellofemoral Syndrome was rated at 10% by VA from 14Jul2012 Left Knee Instability rated at 10% by the VA effective from 01Aug2019. Evidence was insufficient to support that this condition failed retention standards. (31) Recommend: Left Knee Patellofemoral Syndrome with Degenerative Changes in Patellofemoral Compartment and Instability, not in line of duty. (32) Rationale: The applicant did have duty related pain/injury in March 2008, February 2009 and March 2012 (while deployed). The knee showed very good function at the 2012 C&P exam. 3 years later, in September 2015, she fractured the left proximal (the end that articulates with the knee joint) fibula, while not on active orders. The knee MRI showed additional damage described above. h. Left Ankle Sprain (1) 27Mar2008 TMC Physical Therapy In the 6th week of BCT, the applicant was seen for bilateral ankle pain and leg pain of 5 weeks--no known method of injury. (2) 11Nov2015 KY One Health note. Reported left ankle injury in August. Had pain since. No therapy yet. Restrictions given: Avoid squatting, running, hill climbing, driving tactical vehicles, and lifting over 30 pounds. Diagnosis: Left Ankle Sprain. (3) 17Nov2015 release was given from military activities until follow up in 8 weeks (4) Evidence was insufficient to support that this condition failed retention standards. (5) Recommend: Left Ankle Sprain August 2008, Resolved, in line of duty i. Right Ankle Pain (1) 15Mar2008 TMC Ambulatory Clinic. He was seen for bilateral ankle pain. Given a profile until 19Mar2008 and a brief course of physical therapy. (2) 06Aug2008 TMC Ambulatory Clinic. Twisted right ankle during physical training the day prior. He was given work restrictions and told to follow up 9 days. (3) 28Aug2008 FMS, MCWETHY. She stated ankle was much improved. Gait was normal, had right anterior ankle tenderness. Full ROM. Diagnosis: Tendonitis, Overuse Syndrome. (4) 07Jun2018 Right Ankle Film for pain in ankle, showed no fracture or dislocation. Soft tissues were unremarkable. Calcaneal spurs were noted. Minimal degenerative changes were noted in the foot film. (5) Evidence was insufficient to support that this condition failed retention standards. (6) Recommend: Right Ankle Sprain August 2008, Resolved, in line of duty j. Vision Issues. The applicant stated “As a result of taking medication associated with treatment of my knee, I got a condition called ‘Medication Induced Glaucoma’, which resolved after YAG surgery and additional medication, but secondary to that I developed a condition called Papilledema”. (1) 19Apr2012 Optometry Theatre Clinic routine eye exam for complaint of blurry vision. Diagnoses: Blurry Vision, Presbyopia, Refractive Error-Myopia, and Astigmatism. Disc margins were normal (no papilledema). No glaucoma. (2) 07Dec2017 Kentucky Eye Institute (Corbin, KY) note. She reported sudden loss of peripheral vision in the left eye and right eye for one day. There was associated headaches, tearing, and pain around eyes, and nausea. The visual loss is severe in severity, right eye and left are equal. The note indicated that the applicant took Visine, Flexeril and an over-the-counter-antihistamine (later identified as Benadryl) the evening prior to developing the severe eye symptoms. She also had a family history of glaucoma (a brother) and blindness. The diagnosis was Acute Angle Closure Glaucoma (AACG) OU (both eyes). She was treated with laser peripheral iridotomy and seen in follow up 11Dec2017 and 14Dec2017. After surgery, the patient has noticed headache, irritation, and tearing in the effected eye. The specialists considered her risk factors: premature birth, brother with glaucoma; and the evening prior it was reported in one note that she took Flexeril and Visine. In several other notes, it was annotated that she took Flexeril and Benadryl. Regardless, the glaucoma attack resolved and she was advised against taking the medications in the future. (3) 11Dec2017 UK Health Care Ophthalmology. The ophthalmologist wrote that initially, it was thought that Flexeril or Benadryl was the case of the Glaucoma, but now it was uncertain. Although the condition had been treated by laser peripheral iridotomy, he still had left Papilledema, possible sequelae of AACG. (4) 10Jan2018 UK Health Care Ophthalmology. Optic Papillitis (edema or swelling of the optic nerve) of Left Eye was present. (5) 13Apr2018 UK HealthCare Letter from the specialist endorsed that the applicant had AACG - suspected to be induced by Flexeril and Benadryl. (6) 10Aug2018 UK Health Care note. In this note, the neuro-ophthalmologist wrote that the Acute Angle Closure Glaucoma was “possibly induced by Flexeril and Benadryl”. Diagnosis: Bilateral Myopia; Other Localized Visual Defect, Left Eye; Edema of Optic Disc, Left Eye; Choroidal Folds. Of note 20/20 exam showed visual acuity of 20/20 in both the eyes with normal color vision, reduced contrast in the left eye and poor depth perception. Papilledema was still present. (7) 21Aug2018 KEI-Corbin Ophthalmology note. She was being seen for follow up of her anatomically narrow angle, involving the right eye and left eye. Diagnosis: Narrow Angle Glaucoma; Myopia; Pseudotumor Cerebri OS (left eye), rule out. Papilledema was present. (8) 06Nov2018 UK KY Neuroscience Institute. The visit was for a lumbar puncture (LP). The cerebral spinal fluid was normal. Papilledema was absent. She developed a headache after the LP, successfully treated with a blood patch. (9) 28Nov2018 UK KY Neuroscience Institute. Papilledema was present again. Diagnosis: Idiopathic Intracranial Hypertension (or Pseudotumor Cerebri). This condition (and by extension the papilledema) was unrelated to her Glaucoma. (10) The VA deferred rating the eye condition bilateral glaucoma, vitreous floaters and papilledema. Evidence was insufficient to support that this condition failed retention standards. (11) Recommend: Glaucoma, not in line of duty (12) Recommend: Papilledema, not in line of duty. (13) Rationale: The Papilledema was ultimately found to be part of the symptomology of Idiopathic Intracranial Hypertension. The cause was unknown. Although Flexeril and Benadryl medications were initially suspected, at this point, the cause of the Acute Angle Closure Glaucoma remains uncertain. k. Based on review of all available records, medical evidence showed that the applicant’s back, knee, and ankle conditions were resolved or at least not causing duty imitations towards the end of 2016. After October 2016, the applicant’s rehab was focused on the right shoulder condition, and on her developing vision issues. The 27Oct2016 Physical Therapy Discharge Summary showed that she was employed (civilian) full time and was able to perform all duties. And she reported no limitations with her National Guard training. In the ARBA reviewer’s opinion, the applicant’s medical conditions were duly considered during medical separation processing. BOARD DISCUSSION: 1. After reviewing the application, all supporting documents and the evidence found within the military record, the Board determined that partial relief was warranted. The Board carefully considered applicant’s contentions, military record and regulatory guidance. Based on the preponderance of evidence available for review, to include the NCO Evaluation Report for the period 6 May 2015 showing she obtained a Master of Arts degree in Psychology, the Board determined the evidence sufficient to warrant relief for that portion of the request. 2. The Board further determined the evidence presented insufficient to warrant a portion of the requested relief pertaining to the completion of multiple Line of Duty (LOD) investigations, duty-related physical disability retirement or separation. The Board reviewed and concurred with the Medical Review that the applicant’s medical conditions were duly considered and determined the evidence insufficient to warrant further consideration. VOTE: Mbr 1 Mbr 2 Mbr 3 : : : GRANT FULL RELIEF :X :X :X GRANT PARTIAL RELIEF : : : DENY APPLICATION BOARD DETERMINATION/RECOMMENDATION: 1. The Board determined the evidence presented is sufficient to warrant a recommendation for partial relief. As a result, the Board recommends that all Department of the Army records of the individual concerned be corrected by her a National Guard Bureau (NGB) Form 22 (National Guard Report of Separation and Record of Service) to show the award of a master’s degree in Psychology. 2. The Board further determined the evidence presented insufficient to warrant a portion of the requested relief. As a result, the Board recommends denial of so much of the application that pertains to completion of multiple Line of Duty (LOD) investigations or duty-related physical disability retirement or separation. 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. REFERENCES: 1. Title 10, U.S. Code, chapter 61, provides the Secretaries of the Military Departments with authority to retire or discharge a member if they find the member unfit to perform military duties because of physical disability. The U.S. Army Physical Disability Agency is responsible for administering the Army physical disability evaluation system and executes Secretary of the Army decision-making authority as directed by Congress in chapter 61 and in accordance with DOD Directive 1332.18 and Army Regulation 635-40 (Disability Evaluation for Retention, Retirement, or Separation). a. Soldiers are referred to the disability system when they no longer meet medical retention standards in accordance with Army Regulation 40-501, chapter 3, as evidenced in an MEB; when they receive a permanent medical profile rating of 3 or 4 in any factor and are referred by an MOS Medical Retention Board; and/or they are command-referred for a fitness-for-duty medical examination. b. The disability evaluation assessment process involves two distinct stages: the MEB and PEB. The purpose of the MEB is to determine whether the service member's injury or illness is severe enough to compromise his/her ability to return to full duty based on the job specialty designation of the branch of service. A PEB is an administrative body possessing the authority to determine whether or not a service member is fit for duty. A designation of "unfit for duty" is required before an individual can be separated from the military because of an injury or medical condition. Service members who are determined to be unfit for duty due to disability either are separated from the military or are permanently retired, depending on the severity of the disability and length of military service. Individuals who are "separated" receive a one-time severance payment, while veterans who retire based upon disability receive monthly military retired pay and have access to all other benefits afforded to military retirees. c. The mere presence of a medical impairment does not in and of itself justify a finding of unfitness. In each case, it is necessary to compare the nature and degree of physical disability present with the requirements of the duties the Soldier may reasonably be expected to perform because of his or her office, grade, rank, or rating. Reasonable performance of the preponderance of duties will invariably result in a finding of fitness for continued duty. A Soldier is physically unfit when a medical impairment prevents reasonable performance of the duties required of the Soldier's office, grade, rank, or rating. 2. Army Regulation 635-40 establishes the Army Disability Evaluation System and sets forth policies, responsibilities, and procedures that apply in determining whether a Soldier is unfit because of physical disability to reasonably perform the duties of his office, grade, rank, or rating. Only the unfitting conditions or defects and those which contribute to unfitness will be considered in arriving at the rated degree of incapacity warranting retirement or separation for disability. a. Paragraph 3-2 states disability compensation is not an entitlement acquired by reason of service-incurred illness or injury; rather, it is provided to Soldiers whose service is interrupted and who can no longer continue to reasonably perform because of a physical disability incurred or aggravated in military service. b. Paragraph 3-4 states Soldiers who sustain or aggravate physically-unfitting disabilities must meet the following line-of-duty criteria to be eligible to receive retirement and severance pay benefits: (1) The disability must have been incurred or aggravated while the Soldier was entitled to basic pay or as the proximate cause of performing active duty or inactive duty training. (2) The disability must not have resulted from the Soldier's intentional misconduct or willful neglect and must not have been incurred during a period of unauthorized absence. c. Paragraph 4-34 (Reserve Component non-duty related process) describes the Reserve Component non-duty related process and policy. It affords Reserve Component Soldiers not on call to active duty of more than 30 days and who are pending separation by the reserve Component for non-duty related medical conditions to enter the Disability Evaluation System (DES) for a determination of fitness and whether the condition is duty-related. (1) A line of duty (LOD) investigation resulting in a finding of not in LOD is not required when it is clear that the disqualifying disability is non-duty related. For example, a Reserve Component Soldier’s disqualifying condition is an amputation that was incurred when the Soldier was not in a duty status. (2) Referral to the Reserve Component non-duty related process is upon the request of the Reserve Component Soldier. If the Soldier does not request referral, they are subject to separation for medical disqualification under Reserve Component regulations. (3) In the situation of a Reserve Component Soldier having multiple disqualifying conditions, if any one of the conditions was incurred or aggravated in the LOD, the Soldier is not eligible to be processed under the non-duty related process. (4) In the absence of a not in the LOD determination for the non-duty related medical condition, the PEB president has the authority to direct the return of the cause for re-referral under the Integrated (IDES) process. Such action is warranted when the PEB has evidence that the condition was incurred or aggravated in the LOD. For example, the Soldier’s military medical records reflect that the condition was incurred or aggravated when the Soldier was in a duty status. In this situation, the PEB terminates the non-duty related case adjudication. 3. Army Regulation 40-501 provides information on medical fitness standards for induction, enlistment, appointment, retention, and related policies and procedures. Soldiers with conditions listed in chapter 3 who do not meet the required medical standards will be evaluated by an MEB and will be referred to a PEB as defined in Army Regulation 635–40 with the following caveats: a. USAR or Army National Guard (ARNG) Soldiers not on active duty, whose medical condition was not incurred or aggravated during an active duty period, will be processed in accordance with chapter 9 and chapter 10 of this regulation. b. Normally, Reserve Component Soldiers who do not meet the fitness standards set by chapter 3 will be transferred to the Retired Reserve per Army Regulation 140–10 or discharged from the Reserve Component per Army Regulation 135–175 (Separation of Officers), Army Regulation 135–178 (ARNG and Reserve Enlisted Administrative Separations), or other applicable Reserve Component regulation. They will be transferred to the Retired Reserve only if eligible and if they apply for it. c. Reserve Component Soldiers who do not meet medical retention standards may request continuance in active USAR status. In such cases, a medical impairment incurred in either military or civilian status will be acceptable; it need not have been incurred only in the line of duty. Reserve Component Soldiers with non-duty related medical conditions who are pending separation for not meeting the medical retention standards of chapter 3 may request referral to a PEB for a determination of fitness in accordance with paragraph 9–12. d. Paragraph 9-12 states Reserve Component Soldiers with nonduty related medical conditions who are pending separation for failing to meet the medical retention standards of chapter 3 of this regulation are eligible to request referral to a PEB for a determination of fitness. Because these are cases of Reserve Component Soldiers with non–duty related medical conditions, MEBs are not required and cases are not sent through the PEBLOs (Physical Evaluation Board Liaison Officers) at the military treatment facilities. Once a Soldier requests in writing that his or her case be reviewed by a PEB for a fitness determination, the case will be forwarded to the PEB by the USARC Regional Support Command or the U.S. Army Human Resources Command Surgeon’s office and will include the results of a medical evaluation that provides a clear description of the medical condition(s) that cause the Soldier not to meet medical retention standards. 4. National Guard Regulation 600-200 (Enlisted Personnel Management) prescribes the criteria, policies, processes, procedures and responsibilities to classify, assign, utilize, transfer, separate and appoint ARNG and Army National Guard of the Unites States enlisted Soldiers. Paragraph 6-35 (Separation/Discharge from State ARNG and/or Reserve of the Army) section l, provides for the separation of Soldiers found medically unfit for retention per Army Regulation 40-501. 5. Title 10, U.S. Code, section 1201, provides for the physical disability retirement of a member who has at least 20 years of service or a disability rating of at least 30 percent. Title 10, U.S. Code, section 1203, provides for the physical disability separation of a member who has less than 20 years of service and a disability rating of less than 30 percent. 6. Title 10 USC, section 12731b (Special rule for members with physical disabilities not incurred in the line of duty), enacted 23 October 1992, provides in pertinent part that in the case of a member of the Selected Reserve of a RC who no longer meets the qualifications for membership in the Selected Reserve solely because the member is unfit because of physical disability, the Secretary concerned may, for the purpose of Section 12731 of this title, determine to treat the member as having met the service requirement and provide the member notification required if the member completed at least 15 years, but less than 20 years of qualifying service for retirement purposes as of 1 October 1991. This special provision of the law is applicable only to members who are medically disqualified for continued service in an RC. 7. Army Regulation 600-8-4 (Line of Duty Policy, Procedures, and Investigations) prescribes policies and procedures for investigating the circumstances of disease, injury, or death of a Soldier providing standards and considerations used in determining LOD status. a. A formal LOD investigation is a detailed investigation that normally begins with DA Form 2173 (Statement of Medical Examination and Duty Status) completed by the medical treatment facility and annotated by the unit commander as requiring a formal LOD investigation. The appointing authority, on receipt of the DA Form 2173, appoints an investigating officer who completes the DD Form 261 and appends appropriate statements and other documentation to support the determination, which is submitted to the General Court Martial Convening Authority for approval. b. The worsening of a pre-existing medical condition over and above the natural progression of the condition as a direct result of military duty is considered an aggravated condition. Commanders must initiate and complete LOD investigations, despite a presumption of Not In the LOD, which can only be determined with a formal LOD investigation. c. An injury, disease, or death is presumed to be in LOD unless refuted by substantial evidence contained in the investigation. LOD determinations must be supported by substantial evidence and by a greater weight of evidence than supports any different conclusion. The evidence contained in the investigation must establish a degree of certainty so that a reasonable person is convinced of the truth or falseness of a fact. 8. Title 38 U.S. Code 1110 (General - Basic Entitlement) states for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation as provided in this subchapter, but no compensation shall be paid if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. 9. Title 38 U.S. Code 1131 (Peacetime Disability Compensation - Basic Entitlement) states for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during other than a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation as provided in this subchapter, but no compensation shall be paid if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. //NOTHING FOLLOWS// ABCMR Record of Proceedings (cont) AR20200007608 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1