IN THE CASE OF: BOARD DATE: 28 June 2023 DOCKET NUMBER: AR20220010646 APPLICANT REQUESTS: in effect, completion of his DA Forms 2173 (Statement of Medical Examination and Duty Status) with a favorable finding of in line of duty (LOD) for: * a 24 September 2020 shoulder injury occurring during annual training * a 26 April 2021 fall occurring during inactive duty training APPLICANT'S SUPPORTING DOCUMENT(S) CONSIDERED BY THE BOARD: * DD Forms 149 (Application for Correction of Military Record) * DA Form 2173, 5 November 2020, with 12 pages of medical records * Order Number 077873 * Order Number 095011 * DA Form 2173, 4 November 2021, with 21 pages of medical records FACTS: 1. The applicant states: a. LOD case #055-20-003365 [for his shoulder injury] was closed out due to his doctor not filling out his DD Form 2173 correctly. The paperwork was corrected and resubmitted but did not have enough time to process due to his retirement. The injury happened while on duty during annual training orders. The injury is still affecting him and he is entitled to the LOD claim. b. DD Form 2173 was not processed due to administrative issues. The injury [fall] happened 23 April 2021 while on duty during the unit’s battel assembly training. Meniscus tear surgery was performed 1 July 2021. The injury is still affecting him and he is entitled to the LOD claim. 2. The applicant enlisted in the United States Army Reserve on 23 February 1987. He served on initial active duty for training from 28 April 1987 to 27 August 1987. He was mobilized for participation in Operation Enduring Freedom and served on active duty from 2 January 2003 to 19 February 2004. He was notified on 27 March 2008 of his eligibility for retired pay at age 60. 3. The applicant was assigned to the Retired Reserve effective 12 September 2021 for the completion of 20 or more years of qualifying service for retired pay at age 60. 4. The applicant provided: a. Order Number 077873 showing he was ordered to annual training (AT) for 15 days effective 31 August 2020. b. Order Number 095011 amends Order Number 077873 to show he was ordered to AT effective 12 September 2020. c. DA Form 2173, dated 25 November 2020, showing he was treated as an outpatient for an injury to his right shoulder occurring during physical training (PT)/combatives on 18 September 2020. Specifically, the applicant was performing physical training PT, lifting weights in the gym. Right shoulder pulled and popped; grinds at certain lifting movements and limited movement; pain around the joint area. The injury was deemed permanent partial and likely to result in a claim against the government for future medical care. A formal line of duty investigation was not required. The injury considered to have been incurred in the line of duty. d. DA Form 2173, dated 4 November 2021, showing he was treated as an outpatient for a fall on 23 April 2021. It does not provide the specifics of the injury or how it occurred. The injury was deemed temporary and not likely to result in a claim against the government for future medical care. A formal line of duty investigation was not required. The injury considered to have been incurred in the line of duty. 5. In processing this case an advisory opinion from the Army Human Resources Command (AHRC) Surgeon General’s Office on 27 January 2023. The following response was received: a. It is the opinion of the AHRC Surgeon General's office that the medical condition right shoulder injury was service incurred. However, there is insufficient evidence to support the left knee injury was service incurred or service aggravated without reviewing the 26 April 2021 civilian outpatient treatment medical encounter for corroborating evidence. b. The medical evidence documented [the applicant] was initially evaluated for pain in the right shoulder on 24 September 2020 at NHC, Corpus Christi Military Treatment Facility (MTF). He reported to the medical provider that on 18 September 2020 while weightlifting during combative training he felt a "pop" in his right shoulder and was not able to perform specific activities of daily living (ADLs) due to significant pain. The exam demonstrated positive findings for a shoulder injury. The medical provider assessed acromioclavicular arthropathy and possible rotator cuff tendinosis and referred him to Physical Therapy. [The applicant] received physical therapy treatment on 24 September 2020 and 20 November 2020. The physical therapist referred the [applicant] to seek care at the Veterans Affairs (VA) hospital upon expiration of active orders. The record is silent for medical care of the right shoulder from November 2020 until 19 January 2021 when the [applicant] sought a compensation exam for his right shoulder. An X-ray on 13 July 2021 revealed right shoulder "degenerative acromioclavicular (AC) joint" findings. A magnetic resonance imaging (MRI) report dated 10 June 2022 demonstrated significant findings of both AC joint and rotator cuff. These findings are consistent with the exam findings and assessments when [the applicant] was seen at the MTF in September 2020. [The applicant] continues to receive care by a community care orthopedic team for evaluation and treatment of right shoulder AC joint degeneration and right rotator cuff extensive pathology. c. With regards to the left knee injury, the evidence was reviewed for documentation of the incident surrounding the knee injury and if there was any corroborating evidence supporting that documentation. There was a DA 2173, Statement of Medical Examination and Duty with details of the accident only documented "patient had a fall". The extent of the injuries due to the fall were not annotated by the attending physician; furthermore, it was annotated the injury was likely to result in a "temporary" disability. X- rays and MRI were obtained for "left knee pain," which demonstrated positive findings. [the applicant] received surgical treatment for these findings in July 2021 and successful rehabilitated/recovered. 6. The applicant was provided a copy of the advisory opinion via electronic mail on 3 February 2023 for review and comment. The applicant provided 52 pages of medical records in response. 7. MEDICAL REVIEW: a. The Army Review Boards Agency (ARBA) Medical Advisor was asked to review this case. Documentation reviewed included the applicant’s ABCMR application and accompanying documentation, the military electronic medical record (AHLTA), the VA electronic medical record (JLV), the electronic Physical Evaluation Board (ePEB), the Medical Electronic Data Care History and Readiness Tracking (MEDCHART) application, the Army Aeromedical Resource Office (AERO), and/or the Interactive Personnel Electronic Records Management System (iPERMS). The ARBA Medical Advisor made the following findings and recommendations: b. The applicant is applying to the ABCMR requesting affirmative line of duty (LOD) determinations for right shoulder and left knee injuries. He states: “LOD case #055-20-003365 was closed out due to my Doctor not filling out my DD form 2173 correctly. The paperwork was corrected and resubmitted but did not have enough time to process due my retirement. I would like to have my LOD claim processed.” c. The Record of Proceedings details the applicant’s military service and the circumstances of the case. Orders published on 14 June 2021 by the 63rd Readiness Division (USAR) show the applicant was assigned to the Retired Reserve effective 12 September 2021 after having completed 20 or more years of qualifying service for retired pay at age 60. d. Multiple and varied searches for the referenced LOD (#055-20-003365 ) in the electronic line of duty module used by both the Army National Guard and the United States Army Reserve for the initiation and processing of LODs did not locate such a case. e. The Adjutant General of the Army (TAG) oversees and manages the Army’s line of duty processes as directed by the Deputy Chief of Staff, G-1. Paragraph 1-7c1 of AR 600-8-4 Line of Duty Policy, Procedures, and Investigations (15 March 2019): “1–7. Deputy Chief of Staff, G–1 The DCS, G–1 will — c. Maintain functional responsibility for LOD determinations. The following specific tasks may be delegated, but not below The Adjutant General (TAG): (1) Have functional responsibility for LOD determinations and act for the Secretary of the Army (SECARMY) on all LOD determinations and appeals referred to Headquarters, Department of the Army and all exceptions to provisions described in this regulation. f. The United States Army Human Resources Command’s (AHRC) 2 February 2023 Advisory provides an excellent analysis of this circumstances of this case” “It is the opinion of the AHRC Surgeon General's office that the medical condition right shoulder injury was service incurred. However, there is insufficient evidence to support the left knee injury was service incurred or service aggravated without reviewing the 26 April 2021 civilian outpatient treatment medical encounter for corroborating evidence.” g. Their review of his left knee injury is in paragraph 4: “With regards to the left knee injury, the evidence was reviewed for documentation of the incident surrounding the knee injury and if there was any corroborating evidence supporting that documentation. There was a DA 2173, Statement of Medical Examination and Duty with details of the accident only documented "patient had a fall". The extent of the injuries due to the fall were not annotated by the attending physician; furthermore, it was annotated the injury was likely to result in a "temporary" disability. X-rays and MRI were obtained for "left knee pain," which demonstrated positive findings. SFC(R) {Applicant} received surgical treatment for these findings in July 2021 and successful rehabilitated/recovered.” h. Following his receipt of HRC’s advisory, the applicant submitted 52 pages of medical records, approximately one third of which address his left knee injury. There was no 26 April 2021 treatment encounter. i. From his initial evaluation at the Orthopedic Center Corpus Christi on 16 June 2021: “The patient is a 54-year-old male, who presents with complaints of anterior pain and instability in the left knee. The onset was gradual with injury which occurred on 4/23/2021 during ACFT [Army combat fitness test] training with the military. The patient states he was carrying weights on each arm and while doing rush maneuvers, the patient hyperextended his left knee ... MRI Left Knee without contrast Contrast performed on 04/28/2021 at Radiology Associates IMPRESSION: 1. Complex tear of the posterior horn and body of the medial meniscus. Intact medial compartment articular cartilage. 2. Ligamentous edema adjacent to the superficial fibers of the medial collateral ligament which may represent a grade 1 sprain or could be reactive secondary to medial compartment pathology. 3. Moderate semimembranosus tendinosis with adjacent soft tissue edema. Correlate with clinical signs of semimembranosus bursitis. 4. Small knee joint effusion. 5. Mild patellofemoral joint chondrosis. Diagnosis: Pain in left knee Chondromalacia patellae, left knee Complex tear of medial meniscus. current injury, left knee, initial encounter Sprain of medial collateral ligament of left knee, initial encounter j. By this time, the applicant had not improved after 2 months of physical therapy and opted to undergo arthroscopy on 8 July 2021. Findings noted in the operative report included a “complex medial meniscus tear of the posterior horn, radial component and a horizontal cleavage,” grade1 and grade 2 chondromalacia in the medial compartment, and “some grade 2 and small areas of grade 3 chondromalacia in the trochlea” under the patella. The latter two findings of softening and degeneration of the articular cartilage are chronic in nature and not consistent with an acute injury. k. The complex nature of the meniscus tear, particularly with a horizontal cleavage component, make it more likely to have been chronic in nature as well. The applicant’s stated mechanism of injury was “The onset was gradual with injury which occurred on 4/23/2021 during ACFT training with the military.” One would expect an acute onset of pain with some immediate difficulty in ambulating had the applicant sustained a meniscus tear at that time. It is more likely than not that the applicant’s onset of pain that Friday was an exacerbation of underlying pre-existing pathologies than an acute intraarticular injury. l. It is the opinion of the ARBA Medical Advisor that the findings noted in the HRC advisory are correct. In addition, there is insufficient probative information in the new medical documentation to support the overturning of HRC’s line of duty finding for the applicant’s left knee conditions. BOARD DISCUSSION: 1. After reviewing the application and all supporting documents, the Board found the partial relief was warranted. The Board carefully considered the applicant's record of service, documents submitted in support of the petition and executed a comprehensive and standard review based on law, policy and regulation, Upon review of the applicant’s petition, available military records and HRC advisory opinion, the Board noted evidence of record shows the applicant was initially evaluated for pain in the right shoulder on 24 September 2020 where he indicated on 18 September 2020 while weightlifting during combative training, he felt a "pop" in his right shoulder and was not able to perform specific activities of daily living due to significant pain. The Board concurred with the HRC advisory official finding the right shoulder injury was service incurred. Based upon a preponderance of the evidence, the Board determined there is sufficient evidence to grant relief for the injury sustained on 24 September 2020. 2. Additionally, the Board also considered the findings of the medical advisory opinion. The Board noted the latter two findings of softening and degeneration of the articular cartilage are chronic in nature and not consistent with an acute injury. The Board concurred with the medical advisory official finding, after review of the additional medical evidence provided, it is more likely than not that the applicant’s onset of pain was an exacerbation of underlying pre-existing pathologies than an acute intraarticular injury. The Board determined there is insufficient evidence to warrant partial relief for the injury sustained on 26 April 2021. BOARD VOTE: Mbr 1 Mbr 2 Mbr 3 : : : GRANT FULL RELIEF :X :X :X GRANT PARTIAL RELIEF : : : GRANT FORMAL HEARING : : : 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 completing the DA Form 2173 (Statement of Medical Examination and Duty Status) with a favorable finding of in line of duty (LOD) for the shoulder injury occurring during annual training on 24 September 2020. 2. The Board further determined the evidence presented is 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 a favorable finding of in line of duty for the injuries the applicant sustained on 26 April 2021, the fall occurring during inactive duty training. 0I 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. 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. It provides standards and considerations used in determining line of duty (LD) status. The Commanding General, U.S. Army Human Resources Command has functional responsibility for LD determinations and acts for the Secretary of the Army (SA) on all LD determinations and appeals referred to Headquarters, Department of the Army (HQDA) and all exceptions to procedures prescribed in this regulation. Major continental U.S. Army commander will supervise the LD investigation process under their jurisdiction. The general court-martial convening authority (GCMCA) acts as the final approving authority for formal LD determinations on behalf of the SA and may delegate this authority in writing to a field grade officer on the staff of the GCMCA. a. Line of duty determinations are essential for protecting the interest of both the individual concerned and the U.S. Government where service is interrupted by injury, disease, or death. A Soldier of the Army National Guard of the United States or USAR is entitled to hospital benefits, pensions, and other compensation, similar to that for Soldiers of the Active Army for injury, illness, or disease incurred in LD, under the following conditions as prescribed by law (Title 10, U.S. Code, section 1074a): * while performing active duty for a period of 30 days or less * while performing inactive duty training * while performing service on funeral honors duty * while traveling directly to or from the place at which that soldier is to perform or has performed active duty for a period of 30 days or less; inactive duty training; or service on funeral honors duty * while remaining overnight immediately before the commencement of inactive duty training, or while remaining overnight, between successive periods of inactive duty training, at or in the vicinity of the site of the inactive duty training * while remaining overnight immediately before serving on funeral honors duty at or in the vicinity of the place at which the soldier was to so serve, if the place is outside reasonable commuting distance from the soldier’s residence b. The unit commander will ensure the DA Form 2173 is completed promptly and forwarded through channels to the appointing authority. Investigations can be conducted informally by the chain of command where no misconduct or negligence is indicated. Documentation for an informal LD investigation typically consists of DA Form 2173. The military treatment facility commander or an authorized representative (attending physician or patient administrator) will ensure Section I of DA Form 2173 is promptly completed. The unit commander will complete Section II and forward it to the appointing authority or higher authority. The final determination of an informal LD investigation can result in a determination of "in LD" only. The unit commander should complete their regulatory requirements within 30 calendar days of the incident. c. Line of duty determinations must be supported by substantial evidence and by a greater weight of evidence than support any different conclusion. The evidence contained in the investigation must establish a degree of certainty so a reasonable person is convinced of the truth or falseness of a fact. d. The final approving authority will reviewed the LD for completeness and required documents. Upon approval, the approving authority should retain a copy and forward a copy to the Soldier’s official military personnel file for filing in their record. The standard completion time is normally 40 calendar days after the incident. e. Paragraph 4-4 (Time limitations for processing LD actions) states LD should be completed with the prescribed time limits defined in this regulation. When a report is late, comments should be included in the remarks section of the DA Form 2173 for informal reports. It states, "The mere failure to complete an action within the prescribed time or the failure to provide reasons the report is late is not a basis to disapprove, reverse, or change an otherwise proper determination." 2. Army Regulation 638-8 (Casualty and Mortuary Affairs – Army Casualty Program) dated 7 June 2019 and previous editions prescribes the policies and mandates responsibilities, operating tasks, and procedures for the Army Casualty Program. For the purposes of casualty reporting, a casualty is defined as any person lost to an organization by reason of having been declared deceased, duty status-whereabouts unknown, excused absence-whereabouts unknown, missing, injured or ill. Casualty reports, in pertinent part, are required for all USAR and Army National Guard of the United States (ARNG) Soldiers staying at their residence when so authorized by proper authority during the period of such inactive duty training or between successive days of inactive duty training, and/or while enroute to or from, or while participating in the following authorized training activities: * annual training * active duty for training (ADT) * Full-time National Guard duty (FTNGD) (National Guard Soldiers serving pursuant to state active duty orders are not reportable.) * temporary tour of active duty * initial ADT * scheduled inactive duty training (IDT) * active duty for operational support (ADOS) (ARNG/USAR) * contingency operations-active duty for operational support * special ADT 3. Section 1556 of Title 10, United States Code, requires the Secretary of the Army to ensure that an applicant seeking corrective action by the Army Review Boards Agency (ARBA) be provided with a copy of any correspondence and communications (including summaries of verbal communications) to or from the Agency with anyone outside the Agency that directly pertains to or has material effect on the applicant's case, except as authorized by statute. ARBA medical advisory opinions and reviews are authored by ARBA civilian and military medical and behavioral health professionals and are therefore internal agency work product. Accordingly, ARBA does not routinely provide copies of ARBA Medical Office recommendations, opinions (including advisory opinions), and reviews to Army Board for Correction of Military Records applicants (and/or their counsel) prior to adjudication. //NOTHING FOLLOWS// ABCMR Record of Proceedings (cont) AR20220010646 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1