Citation Nr: 1416134 Decision Date: 04/11/14 Archive Date: 04/24/14 DOCKET NO. 09-41 521 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE 1. Entitlement to service connection for a low back disorder. 2. Entitlement to service connection for a right shoulder disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD N. Sangster, Associate Counsel INTRODUCTION The Veteran had active duty from May 1986 to October 2006. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision from the Department of Veteran Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The Board has reviewed the Veteran's physical claims file and the Virtual VA electronic claims file. 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 sincerely regrets the additional delay that inevitably will result from this remand, but it is necessary to ensure there is a complete record and so the Veteran is afforded every possible consideration. The Veteran claims that he has experienced pain in his lower back and right shoulder since active service. He claims that he injured his right shoulder while playing volleyball. A review of his service treatment records (STRs) shows that he was treated in March 1993 for an injury to his right shoulder after playing basketball. He also reported having painful back spasms that caused his back to lock up on his January 2005 Addendum to Medical History. The Veteran had a VA examination in November 2006. At that time, he reported that his right shoulder pain had resolved several weeks after he was treated by a medical technician who strapped his arm to his side. He also stated that his shoulder only ached when he threw a baseball. With regards to his back, he reported getting acute back aches on lifting but that he did not seek medical treatment for his back. The examiner diagnosed the Veteran with right shoulder tendinitis resolved with no residuals, and mechanical low back pain sporadic with no objective findings on examination and no residuals. A review of subsequent treatment records shows that in August 2008 x-rays and a MRI revealed he had a type 2 acromion, supraspinatus tendinosis and focal thickness rotator cuff injury to his right shoulder. He was prescribed pain medication, physical therapy and received cortisone shots that did not resolve his pain. The Veteran had surgical intervention in October 2009 for a right shoulder impingement, rotator cuff tear and biceps tendinitis followed by physical therapy. Also, a review of the medical records shows that images of his lumbar spine revealed minor degenerative endplate findings without evidence of compression fracture; no evidence or spondylolisthesis or spondylolysis within the lumbar spine. Radiology Report dated November 2008. On another VA examination in September 2009, the Veteran was diagnosed with a right shoulder rotator cuff injury with impingement with degenerative joint disease with stability and a lumbar spine myofascial strain without radiculopathy. However, the examiner could not provide an opinion as to whether the Veteran's right shoulder disorder and low back disorder were related to his service without speculation. In light of the foregoing, because the VA examiner did not address the pertinent questions in this case, the Board is of the opinion that a new VA examination, as specified in greater detail below, should be performed in order to determine the nature and etiology of any current shoulder and back disorders. Additionally, any current treatment records should be obtained prior to a decision being rendered in this case. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify all VA and non-VA healthcare providers that have treated him for his right shoulder and/or low back since September 2009. Then, attempt to obtain all records that he adequately identifies. 2. Thereafter, schedule the Veteran for an appropriate VA examination of his right shoulder and lumbar spine. The claims file and a complete copy of this REMAND must be made available to and reviewed by the examiner in conjunction with the examination. The examination report should indicate that this has been accomplished. All necessary studies and tests, including x-rays if indicated, should be conducted. The examiner should identify all current right shoulder and/or low back disorders found to be present. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current right shoulder and/or low back disorder had its clinical onset during active service, or is related to any in-service disease, event, or injury. In providing this opinion, the examiner should acknowledge the Veteran's complaints of back pain on his January 2005 Addendum to Medical History; the November 2008 imaging results of his lumbar spine showing mild degenerative disk changes; his March 1993 in-service treatment for his right shoulder; the August 2008 x-rays and MRI of his right shoulder showing type 2 acromion, supraspinatus tendinosis and focal thickness rotator cuff injury; and October 2009 orthopedic Clinic Notes. A full rationale must be provided for all opinions expressed. 3. Next, review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If the examination report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 4. Finally, after completing the requested actions, and any additional notification and/or development deemed warranted, readjudicate the claims on appeal in light of all pertinent evidence and legal authority. If the benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate SSOC and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. 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.2013). _________________________________________________ P.M. DILORENZO 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) (2013).