Citation Nr: 1324176 Decision Date: 07/30/13 Archive Date: 08/07/13 DOCKET NO. 10-42 484 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire THE ISSUE Entitlement to service connection for bursitis of the right shoulder. REPRESENTATION Appellant represented by: New Hampshire State Veterans Council WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Turner, Counsel INTRODUCTION The Veteran served on active duty from August 1967 to May 1988. This matter comes before the Board of Veterans' Appeals (Board) on an appeal from a rating decision issued by the Regional Office (RO) in Manchester, New Hampshire The Veteran testified from the RO by way of videoconference technology at hearing held before the undersigned Veteran's Law Judge in May 2011. As an initial matter, at the May 2011 hearing, the Veteran's representative contended that the Veteran was already service connected for bursitis of the right shoulder because a November 1988 notice informing him that service connection had been granted for "bursitis," but did not indicate which joint was affected. However, a review of the actual November 1988 rating decision clearly shows that the Veteran was granted service connection for "bursitis, left shoulder status post cystectomy." No subsequent rating decision granted service connection for bursitis of the right shoulder or any other right shoulder condition, and there is no indication that the Veteran ever filed a claim for a right shoulder disability prior to April 2009. 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 Veteran asserts that his bursitis of the right shoulder began during service. At his hearing, he testified that his right shoulder pain had its onset during service and had continued since that time. He did not mention any particular injury. The Veteran contends that he did not mention his right shoulder pain at his exit physical because he was rushed. The Veteran in this regard is shown to have claimed to have problems with hearing loss, indigestion, left shoulder pain, and fatigue in February 1988. He marked "yes" to frequent and painful headaches, hearing loss, skin diseases, frequent indigestion, stomach trouble, cyst, bursitis, painful or trick shoulder or elbow, and recurrent back pain. There is a specific notation that the claims of bursitis and trick or painful shoulder both referred to bursitis of the left shoulder which was first treated in 1984-5. The Veteran claimed at his hearing that he had bursitis of both of his shoulders during service, although there is no documentation that the Veteran had been diagnosed with bursitis of the right shoulder at that time. The only record of a complaint involving the right shoulder in service was a July 1986 treatment record indicating the sudden onset of right shoulder and neck pain with no precipitating event. The diagnosis was that of muscle pain. The Veteran testified that his right shoulder pain had gotten worse since service and started in service after the left shoulder bursitis. He also reported being treated since service for his right shoulder. He was first treated at an Air Force base that was now closed and then at a private facility for 14 years, even though the records received from that facility only date back to 2003. The Veteran explained that the facility told him that they only kept records for seven years. He did not seek VA medical care for his shoulders. The treatment records show that an x-ray study of the right shoulder in September 2003 showed a soft tissue calcification adjacent to the greater tuberosity most consistent with calcific tendonitis or calcific bursitis. The first record of treatment after service regarding the right shoulder was in September 2003, after an emergency room visit the previous night for right shoulder pain. The treatment record indicated that emergency room records showed calcific bursitis. Accordingly, given the Veteran's credible hearing testimony, the Board finds that he should be afforded a VA examination to ascertain the nature and likely etiology of the claimed right shoulder disorder The Veteran reported that he is still receiving treatment for his right shoulder. Thus, he should be asked to provide a release to enable VA to receive these records. Additionally, he should identify and provide a release for the hospital that provided emergency room treatment for his right shoulder in 2003. Accordingly, the case is REMANDED for the following action: 1. The RO should take appropriate steps to contact the Veteran in order to have him identify and provide a release for all treatment records from the hospital where he was treated him in the emergency room for his right shoulder pain in 2003. Also he should be asked to identify and provide a release for any current treatment records for his right shoulder (February 2009 to the present). If releases are provided, all identified treatment records should be obtained. If records are identified, but cannot be obtained, the claims file should document the attempts that were made to obtain the records and the Veteran should be notified of VA's inability to obtain the records. The Veteran should also be informed that he may obtain the records himself and send them to VA. 2. The RO then should have the Veteran scheduled for a VA examination to determine the nature and likely etiology of the claimed right shoulder condition. The examiner should review the entire claims file in conjunction with the examination, including the service treatment records, the VA examination of September 1988, and post-service private treatment records. After reviewing the entire record and examining the Veteran, the examiner should opine as to whether it is at least as likely as not (at least 50 percent likely) that the current right shoulder bursitis (or other diagnosed right shoulder disorder) had its clinical onset during service or otherwise is due to an injury or other event or incident of that service, including the instance of treatment for muscle pain in July 1986 or his use of his arms to perform overhead work while in service. The examiner also should opine as to whether it is as likely as not that any currently demonstrated right shoulder disease process was caused or aggravated by the service-connected left shoulder disability. A complete rationale should be expressed in the report of examination; if the opinion is unfavorable to the Veteran the rationale for this conclusion may not consist merely of the observation that there are no treatment records after service for many years but must be based on sound medical principles. If the examiner is unable to provide the requested opinion without resort to undue speculation, then he or she should explain while this is the case. 3. After completing all indicated development, the RO should readjudicate the claim remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a fully responsive Supplemental Statement of the Case (SSOC) and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ STEPHEN L. WILKINS 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).