Citation Nr: 1306239 Decision Date: 02/22/13 Archive Date: 02/27/13 DOCKET NO. 12-30 831 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Sioux Falls, South Dakota THE ISSUE Entitlement to service connection for residuals of a left shoulder injury. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD R. Anderson, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty for training (ACDUTRA) from June to August 1983 and on active duty from April 2006 to July 2007. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision of the Sioux Falls, South Dakota, Department of Veterans Affairs (VA) Regional Office (RO). The appeal is being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veterans Claim Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012), and the regulations implementing it apply in the instant case. While the notice provisions of the VCAA appear to be satisfied, the Board is of the opinion that further development of the record is required to comply with VA's duty to assist the Veteran in the development of the facts pertinent to his claim. See 38 C.F.R. § 3.159 (2012). The Veteran claims he has a left shoulder disability which resulted from an injury sustained playing football in service in approximately May or June 2006. Lay statements corroborate that a football injury such as the Veteran describes occurred. He asserts entitlement under the chronic disease provisions of 38 U.S.C.A. § 1112 [the Board observes that although arthritis is listed among the chronic diseases that may be service connected on a presumptive basis, other shoulder pathology is not encompassed by those provisions]. The Veteran also sought service connection for a cervical spine disability as resulting from the same incident; the RO has granted him service connection for cervical spine degenerative disease. The Veteran was afforded a VA examination to evaluate his shoulder in October 2011. The examiner opined that "the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness." The rationale for the opinion provided by the examiner was: "There are no STR entries for treatment of his shoulder. Only submitted data is buddy statements which are vague. Vet has not sought any medical care and has not had any restrictions for his shoulder or neck. He does not directly complain of any neck injury or cervical spine pain at this time. He has a small amt of djd of cervical spine on xray. This is nonspecific, minor and most likely is secondary to normal aging process. The small calcification anterior to humeral head on shoulder xray is not in the location of any of the vet's complaints of pain. There was no trigger points in trapezius to make any other muscular diagnosis at this time." This opinion is not adequate for rating purposes. The supporting lay descriptions of the injury are not quite "vague" as described. They specifically point to a fall onto the left shoulder, and there is nothing in the record to suggest that they are not credible. Furthermore, the opinion appears to identify (without providing a diagnosis) an existing left shoulder disability (as it notes calcification in the humeral head), but indicates it is unrelated to service (as it is not at the site of the Veteran's pain complaints), and because there are insufficient findings to support a diagnosis of a soft tissue disability/injury. The opinion does not account for the calcification anterior to the humeral head in region of greater tuberosity, i.e., identify its likely etiology, to include whether the nature of the pathology is consistent with trauma origin. Accordingly, further development in the form of an examination to secure an adequate nexus opinion is necessary. The case is REMANDED to the RO for the following: 1. The RO should arrange for the Veteran to be examined by an orthopedist to determine whether or not he has a chronic left shoulder disability, and if so its nature and likely etiology (and specifically whether it may be related to an injury in service).. The Veteran's claims file must be reviewed by the examiner in conjunction with the examination. Any tests or studies indicated should be completed. Based on examination and interview of the Veteran, and review of the record, the examiner should provide opinions that respond to the following: a) Noting that pain of itself (without underlying pathology) is not a disability please opine whether or not the Veteran has a chronic left shoulder disability? If so, please identify such disability by medical diagnosis(es). If the opinion is that he does not have a chronic left shoulder disability, please comment on the significance of the calcification found on X-ray. b) Please identify the likely etiology for any (and each) left shoulder disability entity diagnosed. Specifically, as to each diagnosis, indicate whether it is at least as likely as not (a 50% or better probability) that such disability is related to/consistent with the type of injury that is described by the Veteran and lay observers. If any disability/pathology found is deemed unrelated to service/injury therein, please identify the etiology that is considered more likely. The examiner must explain the rationale for all opinions, citing to supporting factual data, as indicated. 2. The RO should then review the record, and readjudicate the claim. If it remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). _________________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).