Citation Nr: 1321643 Decision Date: 07/05/13 Archive Date: 07/12/13 DOCKET NO. 09-07 645 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for cellulitis. 2. Entitlement to service connection for a right ear hearing loss. 3. Entitlement to service connection for a bilateral shoulder disability. 4. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Conner, Counsel INTRODUCTION The appellant served on active duty from July 1980 to July 1983. This matter came to the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In May 2011, the appellant testified at a hearing before the undersigned Veterans Law Judge sitting at the RO. In September 2011 and November 2012, the Board remanded the matter for additional evidentiary development and due process considerations. A review of the record shows that the RO has complied with all remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). Neither the appellant nor his representative has argued otherwise. The Board notes that the issues on appeal originally included entitlement to service connection for an upper spine disability. In a September 2012 rating decision, the RO granted service connection for myofascial cervical syndrome, claimed as an upper spine disability, and assigned an initial zero percent disability rating from November 28, 2007, and a 10 percent rating from October 25, 2011. The award of service connection for this disability constitutes a full award of the benefits sought on appeal with respect to the claim of entitlement to service connection for an upper spine disability. The appellant was notified of the RO's determination and his appellate rights in an October 2012 letter but the record currently available to the Board contains no indication that he has initiated an appeal with respect to the downstream elements of initial rating or effective date. Thus, that matter is not currently in appellate status. Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). For the reasons discussed below, a remand is necessary with respect to the issue of entitlement to service connection for a bilateral shoulder disability. This issue is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, D.C. FINDINGS OF FACT 1. The appellant's post-service recurrent cellulitis is not causally related to his active service or any incident therein, an including a July 1980 episode of cellulitis of the right foot. 2. The appellant's current right ear sensorineural hearing loss does not rise to the level of a disability for VA compensation purposes and is shown to be unrelated to his active service or any incident therein, including noise exposure. 3. Hypertension was not clinically evident during the appellant's active service or manifest to a compensable degree within one year of separation from active duty, and the appellant's current hypertension is not causally related to his active service or any incident therein. CONCLUSIONS OF LAW 1. Cellulitis was not incurred in active service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. A right ear hearing loss was not incurred in active service, nor may right ear sensorineural hearing loss be presumed to have been incurred in active service. 38 U.S.C.A. §§ 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2012). 3. Hypertension was not incurred in active service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As a preliminary matter, the Board finds that no further notice or development action is necessary in order to satisfy VA's duties to the appellant under the VCAA. In an October 2007 letter issued prior to the initial decision on the claims, VA notified the appellant of the information and evidence needed to substantiate and complete his claims, and of what part of that evidence he was to provide and what part VA would attempt to obtain for him. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2012). The letter included the additional notification requirements imposed by the Court in Hartman v. Nicholson, 19 Vet. App. 473 (2006). In addition to the notice discussed above, at a conference held in connection with the May 2011 Board hearing, and during the hearing itself, the undersigned discussed the issues on appeal with the appellant and his representative, including the type of evidence required in order to prevail in the claims. 38 C.F.R. § 3.103 (2012); see also Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the hearing, the appellant testified that his physicians had advised him that his claimed disabilities were related to service. The undersigned advised the appellant that it would be to his benefit to submit statements from his physicians memorializing their opinions in this regard. The undersigned held the record open for a period of 60 days following the hearing for the purpose of allowing the appellant to submit this additional evidence, but nothing was received. With respect to VA's duty to assist, the record shows that VA has undertaken all necessary development action. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The appellant has not argued otherwise. The appellant's service treatment records are on file, as are all available post-service clinical records which the appellant has specifically identified and authorized VA to obtain. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c). In that regard, as set forth in more detail below, the record on appeal currently contains civilian post-service treatment records dated from 2002 only. VA has repeatedly requested that the appellant submit or identify earlier records of treatment for his claimed disabilities. Indeed, pursuant to the Board's September 2011 remand, the RO sent the appellant a letter asking him to complete authorization forms to allow VA to obtain earlier treatment records, including records he had mentioned at his May 2011 Board hearing. The appellant, however, did not respond. Under these circumstances, VA has no further duty to assist. The appellant has also been afforded VA medical examinations in connection with his claims. 38 C.F.R. § 3.159(c)(4). The Board finds that the examination reports are adequate and notes that neither the appellant nor his representative has argued otherwise. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that in the absence of a challenge, the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). For the reasons set forth above, and given the facts of this case, the Board finds that no further notification or development action is necessary on the issues now being decided. Background In pertinent part, the appellant's service treatment records show that at his July 1980 military entrance medical examination, no pertinent abnormalities were identified. The appellant's blood pressure was within normal limits, and audiological testing showed pure tone thresholds of zero decibels in all tested frequencies. In connection with the examination, the appellant completed a June 1980 report of medical history indicating a history of elevated blood pressure readings but normal blood pressure since achieving a 35 pound weight loss over a two year period through dieting. In-service treatment records show that in August 1980, the appellant was hospitalized for treatment of an infected fourth digit of the right foot. He was diagnosed as having cellulitis of the right foot. He was treated with incision and drainage and antibiotics and the condition resolved without complication. In June 1981, the appellant underwent a periodic physical examination which was normal in all pertinent respects. Audiological testing showed no hearing loss disability or significant threshold changes in any tested frequency of either ear. The appellant's ears, feet, skin and lymphatics were examined and determined to be normal. The appellant's blood pressure was within normal limits. On a report of medical history completed in connection with the examination, the appellant denied having, or ever having had, a hearing loss, high blood pressure, and/or skin diseases. In January 1982, the appellant underwent a reference audiogram in connection with exposure to noise duties. It was noted that he used triple flange hearing protection and had also been issued earplugs. The reference audiogram showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 0 5 0 LEFT 10 0 0 25 10 The examiner remarked that the appellant had a cold. During a May 1983 initial screening endocrine history, it was noted that the appellant did not exhibit consistently elevated blood pressure nor did he take medication for high blood pressure. Following the appellant's separation from active military service in July 1983, he reportedly joined the reserve. In July 1985, the appellant underwent a periodic examination in connection with his Army Reserve membership. The examination was normal in all pertinent respects. Audiological testing showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 0 -- 0 LEFT 5 0 0 -- 5 In addition, the appellant's ears, feet, skin and lymphatics were examined and determined to be normal. The appellant's blood pressure was 148/80. In a report of medical history completed in connection with the examination, the appellant denied having or ever having had hearing loss, high blood pressure, and skin diseases. In September 2007, the appellant submitted an original application for VA compensation benefits, seeking entitlement to service connection for multiple disabilities, including cellulitis and hypertension, which he indicated had begun in 1980, as well as right ear hearing loss, which he indicated began in 1981. In connection with his claims, VA asked the appellant to submit or identify records showing that his claimed conditions had existed since service. He responded that he had been receiving VA treatment since 2007. In support of the appellant's claim, the RO obtained VA clinical records, dated from 2002 to 2012. In pertinent part, these records show that in May 2002, the appellant sought treatment for a rash on his left lower leg which he indicated had been present for the past three days. He was diagnosed as having cellulitis. In addition, the examiner noted that the appellant was a new VA patient who had recently been diagnosed as having diabetes mellitus. His medications were noted to include Metformin and Lotrel. The following month, the appellant was noted to have hypertension under fair control. No other pertinent complaints or abnormalities were identified. Subsequent VA clinical records show that the appellant continued to receive care for multiple chronic conditions, including diabetes mellitus, hypertension and morbid obesity. In September 2005, he was treated for an episode of cellulitis in the right leg. He reported a history of three to four similar episodes of cellulitis since 1980, all of which resolved with antibiotic treatment. The appellant was again treated for an episode of right leg cellulitis in April 2011. At his May 2011 Board hearing, the appellant testified that following a lengthy march in service, he developed a toe blister which progressed to cellulitis. He recalled being told that his cellulitis was a fungal infection, that there was no way to get rid of it, and that he would have recurrences of cellulitis for the rest of his life. With respect to his claim of service connection for right ear hearing loss, the appellant testified that he had been an infantry officer during active duty and had been exposed to hazardous noise during the course of those duties. He indicated that he had noticed decreased hearing acuity over the years. Finally, the appellant testified that although his service treatment records did not document high blood pressure, he recalled being told when receiving treatment for headaches in service that they were a result of high blood pressure. He also testified that his VA physician had told him that there was a probability that his current hypertension was related to service. In October 2011, the appellant underwent a VA audiology examination. Audiological testing showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 20 25 30 LEFT 5 10 10 10 20 Speech audiometry revealed speech recognition ability of 96 percent, bilaterally. The diagnoses included sensorineural hearing loss in the right ear and normal hearing in the left ear. The examiner indicated that because the claims folder had not been provided to her, she was not able to give an opinion regarding the etiology of the appellant's hearing loss without resorting to speculation. In a November 2011 addendum, the examiner indicated that she had since reviewed the appellant's claims folder and noted that multiple audiograms conducted between 1980 and 1985 had been within normal limits. She further noted that hearing thresholds had been normal on October 2011 audiogram, but for a slight sensorineural hearing loss on the right at 4,000 hertz, which was not a ratable hearing loss disability for VA purposes. She opined that the appellant's slight right ear hearing loss was less likely as not the result of military noise exposure. She noted that multiple military audiograms showed normal hearing thresholds, with no significant shifts. She further noted that the appellant had acknowledged post-service occupational noise exposure as a truck driver for the prior 17 years. In September 2012, a VA physician indicated that he had reviewed the entire claims folder, including the appellant's service treatment records, his lay statements and hearing testimony, and the results of the October 2011 VA audiology examination. Based on that review, the VA physician opined that the appellant's right ear hearing loss was less likely than not incurred in or caused by service. He explained that although the appellant had reported significant in-service noise exposure, he did not complain of or exhibit any significant hearing loss at any tested frequency on multiple in-service audiograms. He further explained that the appellant's current minimal right ear sensorineural hearing loss was consistent with age related hearing loss, also known as presbycusis. At an October 2011 VA medical examination, the appellant reported that he had developed cellulitis during active duty. He indicated that after service, he continued to experience episodes of cellulitis. The examiner indicated that after examining the appellant and reviewing his claims folder, that it was less likely than not that the appellant's post-service cellulitis was causally related to his active service or any incident therein, including his in-service episode of cellulitis. The examiner noted that the appellant had been hospitalized in 1980 for treatment of cellulitis in his right foot. The examiner explained that at that time, there was a documented portal of entry for bacteria, i.e. through the appellant's blister. He noted that cellulitis in the military secondary to infected blisters was very common. In the appellant's case, his in-service cellulitis was successfully treated and resolved without sequelae. The examiner further noted that cellulitis was not thereafter again diagnosed until 2002, when the appellant was diagnosed with diabetes mellitus. The examiner explained that cellulitis and other infections were more prevalent in diabetics than nondiabetics. Given the record, the examiner indicated that it was less likely than not that the appellant's recurrent cellulitis was related to his active service or any incident therein, including the 1980 episode of cellulitis. At an October 2011 VA hypertension examination, the appellant reported bring diagnosed with hypertension in 1996 and was currently taking three medications to control his blood pressure. The examiner indicated that after examining the appellant and reviewing his claims folder, that it was less likely than not that the appellant's current hypertension had been incurred in or was causally related to his active service. The examiner explained that although the appellant had reported a history of elevated blood pressure readings prior to service, his blood pressure had been normal at entry and throughout his period of active duty. He noted that the appellant was not thereafter diagnosed as having hypertension until 1996, many years after service separation. Additional VA clinical records show that the appellant continued to receive treatment for multiple chronic conditions, including hypertension. A progress note indicates that in May 2011, the appellant asked that his physician provide him with an addendum stating that his hypertension, right ear hearing loss, and recurrent cellulitis were just as likely as not to have been related to his previous military service. The VA clinical records, however, contain no indication that such an opinion was provided. In March and April 2012, the appellant was again treated for left lower extremity cellulitis, recurrent, most consistent with a Streptococcal infection. At that time, the appellant reported that he had had eight previous cellulitis infections since 1980. During an April 2012 routine examination, the examiner noted that the appellant did not have a hearing loss. Applicable Law Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain enumerated chronic diseases, including hypertension and an organic disease of the nervous system like sensorineural hearing loss, may be also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). In addition to the criteria set forth above, service connection for impaired hearing is subject to the additional requirement of 38 C.F.R. § 3.385, which provides that impaired hearing will be considered to be a disability only if at least one of the thresholds for the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; the thresholds for at least three of the frequencies are greater than 25 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent. Hensley v. Brown, 5 Vet. App. 155 (1993). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Analysis Cellulitis The appellant seeks service connection for cellulitis. He argues that his current recurrent cellulitis had its inception during active duty, as evidenced by his treatment for cellulitis of the right foot in 1980. After carefully considering the record on appeal, the Board finds that the preponderance of the evidence is against the claim. As set forth above, the record confirms that the appellant was treated during service for one episode of cellulitis in 1980. These records further indicate, however, that his infection was successfully treated with antibiotics and it resolved without sequelae. The remaining service treatment records are entirely negative for any indication of cellulitis. Moreover, the post-service clinical record contains no diagnosis of cellulitis until 2002, nearly twenty years after service separation, and coincident with a diagnosis of recent onset diabetes mellitus. As delineated in detail above, in October 2011, a VA medical examiner reviewed the record and concluded that it was less likely than not that the appellant's post-service recurrent cellulitis was causally related to his active service or any incident therein, including the 1980 episode of cellulitis. This medical opinion is persuasive and assigns it great probative weight. The opinion was rendered by a medical professional with the expertise necessary to opine on the question at issue in this case. In addition, the examiner interviewed and examined the appellant and reviewed his claims folder, factors which further increase the weight of his opinion. The examiner specifically addressed the appellant's medical history, the contentions presented, and provided a rationale for his conclusion. Finally, there is no other medical opinion evidence of record which contradicts the October 2011 VA medical opinion or otherwise suggests that the appellant's current recurrent cellulitis was incurred in service or is otherwise causally related to service. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (discussing factors for determining probative value of medical opinions). In reaching this decision, the Board has carefully considered the appellant's recollections to the effect that he was told during service that his cellulitis was the result of a fungus which could never be eradicated and would recur for the remainder of his life. The Board concludes, however, that his statements are of limited probative value and do not outweigh the evidence discussed above. As set forth in more detail above, the clinical evidence consistently indicates that the appellant's episodes of cellulitis have been of a bacterial origin, including consistent with a Streptococcal infection, and have been successfully treated with antibiotics, indicative of bacterial infection rather than a fungus. There is no indication whatsoever in the clinical record which suggests that his condition is due to a persistent fungal infection which was incurred in service. See also Warren v. Brown, 6 Vet. App. 4 (1993) (holding that a claimant's lay statements relating what a medical professional told him, filtered as they are through a layperson's sensibilities, are too attenuated and inherently unreliable to constitute competent evidence to support a claim). In summary, the Board finds that the most probative evidence shows that the appellant's in-service episode of cellulitis in 1980 resolved without residual disability and that his current recurrent cellulitis is not causally related to the appellant's active service or any incident therein, including the 1980 episode of cellulitis of the right foot. For these reasons, the preponderance of the evidence is against the claim of service connection for cellulitis. 38 U.S.C.A. § 5107(b). Right ear hearing loss The appellant claims that service connection for right ear hearing loss is warranted, based on his exposure to acoustic trauma during active service. The Board notes that the appellant has, indeed, provided credible statements of in-service noise exposure. Moreover, his DD Form 214 corroborates his reported duties as an infantry officer, a position consistent with noise exposure. These facts alone, however, do not provide a sufficient basis upon which to grant the claim. As discussed above, service connection for impaired hearing is subject to the requirements of 38 C.F.R. § 3.385, a provision which specifically defines the level of impaired hearing which constitutes a disability for VA compensation purposes. In this case, the Board has carefully reviewed the record on appeal, but finds no probative evidence showing that the appellant currently has right hearing loss to the extent necessary to constitute a disability for service connection purposes under 38 C.F.R. 3.385. In fact, the appellant's claims folder, containing audiometric test results spanning more than three decades, does not contain one single piece of probative evidence showing that the appellant has ever had a right ear hearing loss disability for VA compensation purposes under 38 C.F.R. § 3.385. Congress specifically limits entitlement for service- connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110, 1131; Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (holding VA's interpretation of the provisions of 38 U.S.C.A § 1110 to require evidence of a present disability to be consistent with congressional intent). In other words, the law limits entitlement to compensation to cases where the underlying in-service incident has resulted in a current disability. Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Here, while there is evidence of in-service acoustic trauma, because the most probative evidence shows that the appellant does not have a current right ear hearing loss disability, as defined by the applicable regulation, the claim must be denied. Moreover, although the appellant has been diagnosed as having a mild sensorineural hearing loss in the right ear, which is not sufficient to rise to the level of disability for VA compensation purposes, the probative medical opinion evidence set forth above indicates that such decreased hearing acuity is not causally related to the appellant's active service or any incident therein, including noise exposure. In reaching this decision, the Board considered the appellant's contentions to the effect that he experiences decreased hearing acuity, such as when using his CB radio. Although the Board is sympathetic to the appellant, in the context of this case, the objective audiometric examination reports are entitled to more probative weight than his own perceptions of his hearing acuity in determining whether a current hearing disability exists. Barr v. Nicholson, 21 Vet. App. 303 (2007). Such a determination is made by a mechanical application of audiometric test findings to the specific criteria set forth in 38 C.F.R. § 3.385. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). In this case, the numeric designations shown on audiometric testing and speech recognition tests indicate that the appellant's right ear hearing loss is not severe enough to constitute a disability for VA compensation purposes. As the preponderance of the evidence is against the claim of service connection for right ear hearing loss, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107. Hypertension The appellant seeks service connection for hypertension. He contends that a military medical provider advised him during service that he had high blood pressure which was causing headaches. He also testified that his VA physician has told him that there is a probability that his current hypertension is related to service. After carefully considering the record on appeal, the Board finds that the preponderance of the evidence is against the claim. As a preliminary matter, the most probative evidence establishes that the appellant did not develop hypertension in service or until many years thereafter. As set forth in more detail above, the appellant's service treatment records are entirely negative for diagnoses of hypertension. Rather, the service treatment records affirmatively show that the appellant's blood pressure was measured on multiple occasions during active duty and it consistently remained within normal limits and was not persistently elevated. As noted, the record contains a May 1983 screening report which specifically notes that the appellant did not exhibit consistently elevated blood pressure nor did he take medication for the disorder. Similarly, the post-service record on appeal shows that the appellant was not diagnosed as having hypertension within the first post-service year or for many years thereafter. He has not contended otherwise. Indeed, he reports that he was not diagnosed as having hypertension until 1996, approximately fourteen years after separation from active service. In reaching its decision, the Board has considered the appellant's statements to the effect that he recalls being told during service that he had hypertension. After weighing the appellant's statements against the other evidence of record, however, the Board assigns his statements limited probative value. As set forth above, the contemporaneous clinical evidence establishes that the appellant did not have hypertension during active duty. The service treatment records show that he did not have persistently elevated blood pressure readings nor was he ever diagnosed as having hypertension during active duty. Moreover, in June 1981 and July 1985, the appellant underwent periodic physical examinations. On both occasions, the appellant completed a report of medical history and specifically denied having or ever having high blood pressure. The Board assigns far more probative weight to the contemporaneous record than to the recollections of the appellant of events which occurred many years previously. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that the contemporaneous evidence has greater probative value than history as reported by a claimant). In summary, the Board finds that the most probative evidence establishes that hypertension was not present during the appellant's active service or manifest to a compensable degree within one year of separation from active duty. The Board also notes that the record on appeal contains no probative evidence that the appellant's post-service hypertension is causally related to his active service or any incident therein. Indeed, in October 2011, a VA examiner concluded that it is less likely than not that the appellant's current hypertension had been incurred in or was causally related to his active service. This medical opinion is persuasive and is assigned great probative weight. The opinion was rendered by a medical professional with the expertise necessary to opine on the question at issue in this case. In addition, the examiner interviewed and examined the appellant and also reviewed his claims folder, factors which further increase the weight of his opinion. The also specifically addressed the appellant's medical history and contentions and has provided a rationale for his conclusion. Finally, there is no other medical opinion evidence of record which contradicts the October 2011 VA medical opinion or otherwise suggests that the appellant's current hypertension was incurred in service or is otherwise causally related to service. Nieves-Rodriguez. Here, the Board notes that it has considered the appellant's assertions to the effect that his VA physician has advised him that there is a probability his current hypertension is related to service. The Board has reviewed more than ten years of the appellant's VA clinical records and can find no indication that any VA physician has memorialized such an opinion, nor did the appellant submit such a medical opinion despite being advised to do so. Given these factors, the Board finds that the appellant's statements regarding what his VA physician told him do not outweigh the October 2011 VA medical opinion discussed above. In summary, the Board finds that the appellant's hypertension was not present in service or for many years thereafter and his current hypertension is not causally related to his active service or any incident therein. Under these circumstances, the Board finds that the preponderance of the evidence is against the claim of service connection for hypertension. 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for cellulitis is denied. Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for hypertension is denied. REMAND The appellant also seeks entitlement to service connection for right and left shoulder disabilities which he contends are causally related to a neck and shoulder injury sustained in a February 1981 vehicle accident. Pursuant to the Board's previous remands, the appellant underwent VA medical examinations in October 2011 and January 2013 after which the examiners concluded that the appellant's current right and left shoulder disabilities were not causally related to his active service or any incident therein, including his February 1981 accident. As set forth above in the Introduction portion of this decision, however, the RO has recently granted service connection for myofascial cervical syndrome. At his May 2011 Board hearing and in clinical settings, the appellant has described shoulder pain which radiates from his neck. In light of that award of service connection for that disability, and given the evidence of record, the Board finds that an additional medical opinion is necessary in order to address the question of whether the appellant's current right and/or left shoulder pain may be causally related to or aggravated by his now service-connected cervical spine disability. See 38 C.F.R. § 3.310(a); McLendon v. Nicholson, 20 Vet. App. 79 (2006) (holding that an examination is necessary when the record indicates that a current disability may be associated with a service-connected disability). Accordingly, the case is REMANDED for the following actions: 1. The RO/AMC should forward the appellant's claims folder to the examiner who conducted the January 2013 VA medical examination and provided the March 2013 addendum, if available. Otherwise, the appellant should be scheduled for a new VA medical examination to be conducted by an orthopedist. His claims folder and access to his Virtual VA file must be made available to all examiners for review in conjunction with the examination. In any case, the examiner must opine whether it is at least as likely as not that the appellant's current right and/or left shoulder disabilities are causally related to or aggravated by his service-connected myofascial cervical syndrome. A complete rationale for all opinions expressed by the examiner should be provided. 2. Thereafter, the RO/AMC must review the record and ensure that the foregoing development actions, as well as any other development that may be in order, has been conducted and completed in full. The RO/AMC must review the examination report to ensure that it is in complete compliance with the directives of this remand. If any report is deficient in any manner, the RO/AMC must implement corrective procedures at once. 3. After undertaking any additional development deemed necessary, the RO should readjudicate the claim, considering all of the evidence of record. If the benefit sought on appeal remains denied, the appellant and his representative should be provided with a supplemental statement of the case and given the opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs