Citation Nr: 1333536 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 12-01 782 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to service connection for a left shoulder disability. REPRESENTATION Appellant represented by: Calvin Hansen, Attorney at Law ATTORNEY FOR THE BOARD D. Havivi, Associate Counsel INTRODUCTION The Veteran had active service from July 1972 to January 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. A review of the Virtual VA paperless claims processing system and the Veterans Benefits Management System reveals no additional records which are pertinent to the present appeal. 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 The Board finds it necessary to remand for further development and a more complete VA examination and opinion. Because the VA undertook to give the Veteran an exam in March of 2009, it must ensure that the exam and opinion are adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran's service treatment records show that he was treated for a left shoulder injury in August 1974. He complained of pain, though he had full range of motion and no tenderness. The medical provider's impression was muscle spasm. The Veteran was told to return for further care as needed, but there is no record of further shoulder care in his service treatment records. In May 2011, the Veteran submitted a statement regarding his left shoulder, asserting that he "banged it once in boot camp and once or twice with my job while in the military at my regular duty bases." He is competent to give these statements, as they describe what he has experienced. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). His statement regarding the August 1974 injury is credible, because there is a corroborating record for its treatment. Despite the lack of corroborating evidence, the Veteran's statement regarding his other shoulder injuries can also be taken as credible. See Buchanan v. Nicholson, 451 F.3d 1331, 1335-36 (2006) (lay evidence of medical symptoms does not have to be accompanied by contemporaneous medical records and a determination that the lack of corroboration would render them incredible would be improper). The VA examiner failed to take into account these lay statements, and therefore the examination is inadequate for adjudication purposes. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury but relied on the service medical records to provide a negative opinion). Upon re-examination, the examiner must elicit from the Veteran a full history of the shoulder injury take into account the credible statements regarding his in-service shoulder injuries that the Veteran has already made. Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony). The Veteran also obtained private medical treatment from Dr. M.J.P. At this examination, the Veteran asserted that he remembered a specific event where he had a tearing and popping sensation in his shoulder. The examiner read the Veteran's medical history and stated that the service treatment record diagnosed a sprain and would monitor it over time. The Veteran stated to the examiner that he had been pushing on an engine when he felt a pop and pain. The examiner found moderate grinding in the left shoulder and decreased range of motion. The examiner opined that there was a probably rotator cuff injury or arthritis. He suspected it was from the Veteran's injury in 1974. The private examiner's conclusion does not include a rationale. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). On remand, an addendum opinion should be obtained from Dr. M.J.P., to include a full rationale which supports his conclusion. Accordingly, the case is REMANDED for the following actions: 1. The RO is directed to ask the Veteran to obtain an addendum opinion from his private examiner, Dr. M.J.P. In this addendum opinion, the private examiner should include a full rationale which supports his conclusion. A recitation of facts used in the rationale should be clearly set forth. 2. The Veteran should also be afforded a VA examination by a medical professional with sufficient expertise to determine the nature and etiology of any currently left shoulder disability. At the examination, the examiner should elicit from the Veteran a full history of the shoulder injury and take it into account when rendering an opinion. Based on these results, the medical professional must render an opinion as to: Whether any diagnosed left shoulder disability is at least as likely as not (at least a 50 percent probability) causally or etiologically related to any incident of the Veteran's service, including and commenting on the Veteran's credible statements regarding his in-service shoulder injuries, both corroborated and uncorroborated. Although there has not yet been a credibility assessment for any new lay statements, such as those elicited concerning the injury's history, they too must be considered and commented upon. A clear rationale for all opinions is required, including a discussion of the facts and medical principles involved. 3. Then, the RO shall then take such additional development action as it deems proper with respect to the claim. When the development has been completed, the case should again be reviewed on the basis of the additional evidence and readjudicated. If the benefits sought are not granted, the Veteran and his representative should be furnished Supplemental Statement of the Case and be afforded a reasonable 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). 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). _________________________________________________ MICHAEL D. LYON 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).