Citation Nr: 0014393 Decision Date: 05/31/00 Archive Date: 09/08/00 DOCKET NO. 97-34 417 DATE MAY 31, 2000 On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for right shoulder disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Neil T. Werner, Associate Counsel INTRODUCTION The veteran served on active duty from September 1948 to February 1949 and from January 1950 to December 1953. This matter comes before the Board of Veterans' Appeals (Board) following a July 1997 decision of the Pittsburgh, Pennsylvania, Regional Office (RO) of the Department of Veterans Affairs (VA) which denied the veteran's claim of service connection for residuals of a right shoulder injury. The Board remanded the veteran's appeal in June 1999 for further evidentiary development. FINDING OF FACT The veteran has right shoulder arthralgia that likely is the result of an in-service injury. CONCLUSION OF LAW The veteran has right shoulder arthralgia that is the result of injury incurred in military service. 38 U.S.C.A. 1110, 5107 (West 1991); 38 C.F.R. 3.303 (1999). REASONS AND BASES FOR FINDING AND CONCLUSION The veteran contends that he has a right shoulder disability that can he attributed to service. Specifically, he has asserts that he injured his right shoulder in a motor vehicle accident while on active duty sometime in the autumn of 1950. He reported that, since that time, he has experienced severe shoulder pain which, among other things, interferes with his sleep. It is also requested that the veteran be afforded the benefit of the doubt. 2 - Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred or aggravated in the line of duty in the active military service. 38 U.S.C.A. 1110, 1131 (West 1991); 38 C.F.R. 3.303(a) (1999). When disease is shown as chronic in service, or within a presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected unless clearly attributable to intercurrent causes. 38 U.S.C.A. 1101, 1112 (West 1991); 38 C.F.R. 3.303(b), 3.307, 3.309 (1999). A review of the veteran's service medical records, including May 1950 treatment records from Sheppard Air Force Base, Wichita Falls, Texas and part of a December 1953 separation examination, reveal no complaints, diagnoses, or treatment for a right shoulder injury. At a general medical VA examination that appears to have been conducted in June 1997, the examining physician reported that the veteran had a history of a right shoulder fracture in 1950. The examiner also opined that the veteran was status- post right shoulder fracture with residual pain. He suggested by his comments that the trauma was sustained in 1950. At a June 1997 VA joints examination, the examiner, after noting the veteran's claim that he injured his right shoulder in 1950, diagnosed post-traumatic impingement syndrome of the right shoulder. However, right shoulder x-rays, dated in June 1997, apparently did not show an old fracture. VA treatment records, dated from August 1997 to October 1997, were received by the RO. Treatment records, dated in October 1997, included the veteran's claim that he had chronic right shoulder pain because of a "war injury." They also indicated that the examiner believed that the veteran had chronic right shoulder pain that was probably due to an old injury. The veteran testified at a personal hearing at the RO in January 1998. He reported that, in approximately October.1950, while in Wichita Falls, Texas, he was asleep 3 - in the front passenger seat of his car when it collided with another car. In the accident, his head struck both the front and side windows, breaking them, and his right shoulder struck the dashboard. While the car belonged to him, an Airman Beals was driving it at that time. The veteran indicated that Airman Beals was not injured. However, he was taken to the base hospital for treatment. The veteran said that his right shoulder was x-rayed, he was told his right shoulder was shattered, and he was placed in a body cast that extended from his waist up to his neck. He wore the cast for approximately one month. Neither the veteran nor the driver of the other car had insurance and therefore insurance claims were not filed. Following the removal of the cast, he did not undergo follow-up treatment. In fact, his first post-accident treatment took place in approximately May 1997 at the Erie VA medical center (VAMC). The veteran also testified that he did not see a physician earlier, despite right shoulder pain that caused problems sleeping, because he did not like to see doctors and he had pain medication from an unrelated back injury that he took to help relieve his right shoulder pain. At the personal hearing the veteran submitted copies of two photographs. The first photograph was of the car that was allegedly damaged in the 1950 accident. This picture shows an automobile with its front and right front panel very heavily damaged as well as its front and right side windows cracked. The second photograph reportedly shows the veteran and the driver of the car sitting on a car while in uniform. In September 1999, the veteran filed a statement with the RO wherein he reported that it was no longer possible to obtain the accident report for the 1950 accident because such reports were only kept by the Texas police for ten years. The veteran also filed a statement from his brother. The veteran's brother reported that, in the fall of 1950, his sister had told him that the veteran had been involved in a motor vehicle accident and that he had injured his shoulder, but was otherwise okay. At an October 1999 VA joints examination, the examiner noted the veteran's claim that he was involved in a motor vehicle accident in 1950 which caused injury to his right shoulder. It was also reported that, the veteran had been required to wear a 4 - cast for six weeks following the accident. Next, it was reported that, since his separation from military service, he had had little if any pain in his right shoulder and had had no right shoulder treatment until two years earlier. At that time, he sought treatment because of right shoulder pain. The clinical impression was "[p]ost history of a[n] injury to the right shoulder with secondary mild arthralgia." The examiner also opined that [i]t is felt that [the] original injury in 1950 has effected and caused the present shoulder condition. It is noted the [veteran] has no similar problems referable to the left shoulder with normal aging and activity wear and tear and thus I feel that the problem present today is the result of the 1950 occurrence. The occurrence originally did not cause enough symptomatology to warrant any medical treatment. The symptoms worsened about two years ago. Initially, the Board observes that nothing about the evidence of record contradicts a finding that the veteran indeed experiences a right shoulder disability, which disability was the result of some earlier trauma. The question that needs to be resolved is whether the trauma that led to the shoulder disability was in fact sustained in service. As noted above, the record on appeal includes the veteran's statements that he injured his right shoulder in a motor vehicle accident while in military service in 1950, his brother's second- hand account of this accident and injury, photographs of the car that was allegedly damaged in the accident as well as the veteran and driver of the car, and opinions from VA physicians that the veteran's current right shoulder disability arose from the alleged in-service injury. On the other hand, the record suggests that the veteran did not require treatment for his right shoulder at the time, at least none that was documented by the service department, or for more than a forty-year period following the veteran's separation from military service. - 5 - The veteran's version of events in service is not corroborated by service department records, but it is corroborated by his brother. Consequently, resolving reasonable doubt in the veteran's favor on this point, the Board finds that the veteran was likely involved in a motor vehicle accident during service that resulted in some degree of trauma to the right shoulder. As suspicious as it may appear to a lay person that current disability would exist following trauma so long ago, especially trauma that was apparently so minor that no treatment was required until about 1997, this question is a medical matter which requires the exercise of medical judgment. To answer this question, the Board remanded the case to the RO in June 1999. After a review of the claims file, which review presumably took into account the absence of complaints or treatment for so many years after the automobile accident, the examiner indicated that current disability is indeed the result of the in-service accident. Consequently, the Board finds that a grant of service connection for right shoulder arthralgia is warranted. ORDER Service connection for right shoulder arthralgia is granted. MARK F. HALSEY Member, Board of Veterans' Appeals 6 -