Citation Nr: 1604476 Decision Date: 02/08/16 Archive Date: 02/18/16 DOCKET NO. 14-20 091 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for right shoulder disability. 2. Entitlement to service connection for disability of the lower neck. 3. Entitlement to service connection for disability of the upper back. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from October 1963 to October 1965. This matter comes before the Board of Veterans' Appeals (Board) on an appeal from an August 2010 rating decision issued by the Los Angeles, California Regional Office (RO) of the Department of Veterans Affairs. In that decision, the RO denied service connection for disabilities of the right shoulder, lower neck, and upper back. In May 2015, the Veteran had a Board videoconference hearing before the undersigned Acting Veterans Law Judge. A transcript of that hearing is in the Veteran's claims file. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran contends that current disabilities of the right shoulder, lower neck, and upper back resulted from an incident in service in 1964, when he fell off of the ladder on a fuel tank and sustained injuries on landing. Service treatment records show treatment of a right hand injury after a fall in March 1964. The Veteran acknowledges that the service treatment record addressed injury of the right wrist or hand, but he reports that he also had pain in his right shoulder after the fall. The Veteran reports that in 2004 he had onset of pain in his right shoulder, lower neck, and upper back. The claims file contains records of medical treatment in June 2004 for sudden onset of pain in the neck and the left shoulder and arm. Subsequent medical records reflect ongoing reports of neck pain. Imaging has shown cervical spine intervertebral disc disorder. From 2009 forward, some treatment records reflect reports of pain in the right shoulder. Other treatment records note shoulder problems, without specifying which shoulder is affected. The report of March 2015 MRI of an unspecified shoulder shows a tear of the supraspinatus tendon. In VA treatment in December 2010, the Veteran reported chronic right shoulder pain. He related having fallen during service in the 1960s. The treating physician noted that November 2009 x-rays showed arthritis in the right shoulder. The physician indicated that the arthritis was likely traumatic arthritis, considering the history of a fall in 1960s. In the 2015 Board hearing, the Veteran stated that treating clinicians have indicated that his right shoulder, lower neck, and upper back disorders could be related to the injury during service. The Veteran has not had a VA medical examination addressing the claims for service connection for disabilities of the right shoulder, lower neck, and upper back. VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The types of evidence that indicate that a current disability may be associated with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon, 20 Vet. App. at 83. The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. The record contains evidence of signs or symptoms of current disabilities of the right shoulder, lower neck, and upper back. A VA physician has suggested a likely link between the fall in service and current right shoulder disability. There is no indication, however, that that physician saw the service treatment record that noted only hand injury after the fall. The record therefore does not contain sufficient information to make a decision on the claim. The Board is remanding the claims for a VA medical examination, with review of the claims file, and opinion as to the likelihood of a connection between injury in service and the current disorders in the right shoulder, lower neck, and upper back. In addition, it is not clear that the Veteran's complete VA treatment records have been assembled. On remand, records from January 2014 through the present from the Sepulveda (California) Ambulatory Care Center and the Lancaster (California) Community Based Outpatient Clinic should be obtained and added to the file. Accordingly, the case is REMANDED for the following action: 1. Obtain records of all treatment of the Veteran from January 1, 2014, forward, at the VA Sepulveda (California) Ambulatory Care Center and the VA Lancaster (California) Community Based Outpatient Clinic. Associate those records with the claims file. 2. Schedule the Veteran for a VA medical examination to address the nature and likely etiology of current disorders affecting the right shoulder, lower neck, and upper back. Provide the Veteran's claims file to the examiner for review. Ask the examiner to review the claims file and examine the Veteran. Ask the examiner to provide a diagnosis for each current disorder affecting the right shoulder, lower neck (cervical spine area) and upper back (thoracic spine area). With respect to each current disorder affecting the right shoulder, lower neck, or upper back, ask the examiner to provide opinion as to whether it is at least as likely as not (at least a 50 percent likelihood) that the disorder is related to injury or other events in service, including a fall during service in 1964 that was followed by treatment for right wrist and hand injury. Ask the examiner to explain the conclusions reached. 3. Thereafter, review the expanded record and reconsider the remanded claims. The Board intimates no opinion as to the ultimate outcome of the matters that the Board has remanded. The Veteran has the right to submit additional evidence and argument on those matters. 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 2014). _________________________________________________ R. FEINBERG Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2015).