Citation Nr: 1325154 Decision Date: 08/08/13 Archive Date: 08/13/13 DOCKET NO. 09-23 254A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for chronic residuals of tendon injuries to the biceps. 2. Entitlement to service connection for cervical strain. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Carsten, Counsel INTRODUCTION The Veteran served on active duty from February 1997 to April 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2008 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. The case was certified to the Board by the RO in St. Petersburg, Florida. The Veteran failed to report for a scheduled June 2013 travel board hearing. The hearing request is considered withdrawn. See 38 C.F.R. § 20.704(d) (2012). The Virtual VA eFolder has been reviewed and contains relevant documents. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND Under the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to assist a veteran in the development of a claim. This includes obtaining records and providing a VA examination when necessary. See 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c) (2012). The Veteran receives VA medical treatment. On review, VA medical records were last added to the Virtual VA eFolder in October 2012. On remand, additional relevant records should be obtained. Chronic residuals of tendon injuries to the biceps The Veteran contends that he injured both bicep muscles during service as a result of in-service physical training, and heavy, repetitive lifting as a dental assistant. The Veteran underwent a VA examination in June 2007 following which the diagnosis was bilateral biceps tendon injury, no residual evident. A medical opinion addressing the etiology of the disorder was not, however, provided. A January 2010 VA orthopedic consult shows that the Veteran was seen with complaints of bilateral elbow pain. He reported repetitive heavy lifting on active duty with subsequent pain and swelling in the bilateral bicipital areas. The impression was bicipital tendonitis. Evidence of record shows a current disability. The Veteran is competent to report that he experienced biceps pain during service following heavy lifting and physical training. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Under these circumstances, a VA examination and medical opinion are needed. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Cervical spine strain The Veteran contends that he has neck problems related to military service. A January 2006 service treatment record documents his complaints of intermittent neck pain which he believed was related to posture at work. The assessment was cervicalgia. On VA examination in June 2007, the Veteran reported neck pain after hours of close work as a dental technician. The pain reportedly began in 2002. X-rays were normal. The diagnosis was cervical spine strain. A medical opinion addressing the etiology of the disorder was not, however, provided. A December 2009 VA record shows that the Veteran was seen with complaints of neck pain. He reported that he started experiencing this while he was in the military. Assessment included cervical neck pain with arm numbness intermittently. A February 2010 primary care note indicates that MRI of the cervical spine was normal. Evidence of record shows in-service complaints. The June 2007 VA examination included a diagnosis of a cervical strain and the Veteran continues to report symptoms of current disability, which he relates to military service. On review, a VA examination and medical opinion are needed. McLendon. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should obtain relevant VA records for the period from October 2012 to the present. All records obtained should be associated with the claims folder or Virtual VA eFolder. If the RO cannot locate such records, the RO must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 2. Thereafter, the AMC/RO should then schedule the Veteran for VA examinations to determine the nature and etiology of claimed chronic residuals of tendon injuries to the biceps, and cervical strain. The claims folder must be available for review by the examiner. Additionally, all relevant medical records must be made available to the examiner for review, either in the Virtual VA eFolder, or if the eFolder is not available, then via paper copies. Any and all studies, tests, and evaluations deemed necessary by the examiner must be performed. The examiner is to review all pertinent records associated with the claims and Virtual VA efolders, including the Veteran's service treatment records, post-service medical records, and assertions. The Veteran reports that he experienced biceps pain during service following heavy lifting and he is competent to attest to factual matters of which he had first-hand knowledge. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should identify any current cervical spine and biceps disability. For each diagnosis entered the examiner must opine whether it is at least as likely as not that the disorder is related to the Veteran's military service, including his reported history, as well as his in-service complaints and the assessment of cervicalgia. A complete and full reasoned rationale for all opinions expressed must be provided. 3. After the development requested has been completed, the AMC/RO should review the examination reports to ensure that they are in complete compliance with the directives of this REMAND. If the reports are deficient in any manner, the RO/AMC must implement corrective procedures at once. 4. The Veteran is hereby notified that it is his responsibility to report for the examinations and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. § 3.655 (2012). 5. Upon completion of the above development, and any additional development deemed appropriate, the AMC/RO should readjudicate the issues of entitlement to service connection for chronic residuals of tendon injuries to the biceps, and a cervical spine disorder. All applicable laws, regulations, and theories of entitlement should be considered. If any benefit sought on appeal remains denied, the appellant and his representative must be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. 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 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).