Citation Nr: 1615339 Decision Date: 04/15/16 Archive Date: 04/26/16 DOCKET NO. 10-13 292 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES Entitlement to service connection for a right shoulder disorder, to include tendonitis. Entitlement to service connection for a left shoulder disorder, to include degenerative joint disease. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Marcus J. Colicelli, Associate Counsel INTRODUCTION The Veteran had active service from August 1981 to August 2001. This matter comes before the Board of Veterans' Appeals (BVA or Board) from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Veteran submitted a timely notice of disagreement (NOD) in October 2009; a statement of the case (SOC) was issued in March 2010, and the Veteran perfected his appeal with the timely filing of a VA Form 9 (substantive appeal) in March 2010. The Veteran requested a hearing before the Board. The requested hearing was conducted in January 2016 by the undersigned. A transcript is associated with the claims file. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. In addition to the VBMS claims file, there is a Virtual VA paperless file associated with the Veteran's case. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Although the Board sincerely regrets the additional delay, further development is required prior to adjudicating the Veteran's claim. A remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Specifically, a remand is required to provide the Veteran with a VA examination for her claimed bilateral shoulder disorders and for the purpose of procuring additional medical evidence. The VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2014). In a claim for service connection, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits still triggers the duty to assist if it indicates that the Veteran's condition may be associated with service. McLendon v. Nicholson, 20 Vet. App. 79 (2006) (38 C.F.R. § 3.159(c)(4) presents a low threshold for the requirement that evidence indicates that the claimed disability may be associated with in-service injuries for the purposes of a VA examination). Service treatment records reveal that in September 1982, the Veteran sought help for a "sharp pain @ shoulder on left side" and was told to avoid lifting and apply heat to the area. See September 1982 Chronological Record of Medical Care. The Veteran also sought care for a cold in December 1998 resulting in symptoms throughout her body including left shoulder blade "pain & burning sensation". See December 1998 Chronological Record of Medical Care. The following week, the Veteran reported that pain in the left shoulder, near the scapula, had continued throughout the week. See December 1998 Chronological Record of Medical Care. The physician diagnosed the Veteran with a rhomboid strain and prescribed stretching with no pushups or sit-ups. Id. Post service medical treatment reflects current diagnoses for both of the Veteran's shoulders. Specifically, the Veteran sought treatment in June 2007 for severe right shoulder pain, and was diagnosed with tendonitis of the rotator cuff. See June 2007 Chronological Record of Medical Care. Regarding her left shoulder, the Veteran recently underwent an MRI in December 2013 which demonstrated moderate AC joint degenerative changes and mild to moderate glenohumeral joint degenerative changes. See December 2013 VAMC Radiologic Examination report. The Veteran has submitted several statements attesting to the fact that she suffered from shoulder problems during service and continues to suffer from them today. See January 2016 Board Hearing transcript ("So you had...pain, loss of motion...weakness...Yes. And the burning sensation...I still get, um, right now...I don't have full control of the motion, and I'm losing some of the...strength.") Specifically, the Veteran contends that her military occupational specialty as a postal worker and admin clerk detrimentally affected her shoulders due to her bearing "as much as 80 pounds or more" on a regular basis. Id. ("your duties as postal...unload the trucks...boxes of mail or whatnot that you had to lift on a daily basis...probably anywhere over 50 pounds...what were your duties in, as an administrative clerk...we had to do all the humps and everything...when you did your humps, what was the weight of the pack...well over 80 pounds"). The Board finds that the Veteran is competent to report the onset, nature, severity, and continuity of his headaches, as headaches are the type of disability that is observable by a lay person. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (a lay person is competent to report symptoms based on personal observation when no special knowledge or training is required). For the foregoing reasons, the Board finds that the Veteran is entitled to a VA examination for her claimed bilateral shoulder disorders. See 38 C.F.R. § 3.159(c)(4) (2015); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The examiner should offer an opinion as to whether the Veteran currently has a diagnosis of a shoulder disorder in either arm, and, if so, whether it is related to service, specifically the September 1982 and December 1998 in-service treatment notes. All lay and medical evidence should be considered, to include any assertions of continuity of symptomatology that may be made by the Veteran. In addition, at her hearing the Veteran testified as to receiving physical therapy for her shoulders since her 2001 discharge, and as recently as 2014. See January 2016 Board Hearing transcript ("since 2001, have you been continuously going to TriCare with complaints specific to both your shoulders...Correct...in 2014 was the last time I actually, um, went to physical therapy for the shoulder"). However, there are no physical therapy records from Tri Care physicians associated with the Veteran's claims file. Such should be requested on remand. Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the claims file all updated treatment records. 2. The Veteran should be asked to identify the private physician(s), if any, who treated her for her shoulders, after service, as well as any other private providers who have treated her for the claimed conditions, including physical therapy received through TriCare of Fort Belvoir between 2001 and 2014, and any other non-VA providers. After receiving this information and any necessary releases, contact the named medical provider(s) and obtain copies of the related treatment records which are not already in the claims folder. 3. Thereafter, schedule the Veteran for a VA examination to address the Veteran's claimed bilateral shoulder disorders, to include tendonitis of the right shoulder and degenerative arthritis of the left shoulder. All pertinent evidence, including any relevant information in Virtual VA and VBMS, should be made available to the examiner for review, and such review should be noted in the opinion report. The examiner should determine the following: a. Whether the Veteran has a current left and/or right shoulder disorder, b. If so, whether the Veteran's current shoulder disorders, are at least as likely as not (50 percent or greater probability) related to the Veteran's military service, including her military occupation specialty as a postal worker and administrative clerk requiring daily lifting up to 80 pounds. The examiner is asked to address the June 2007 diagnosis of tendonitis of the right shoulder, and December 2013 diagnosis of degenerative joint disease of the left shoulder. The examiner must also provide comment regarding the Veteran's lay statements of continuity of symptomatology, including her assertions of pain, burning, weakness, and limitation of motion accompanying her MOS duties. 4. Then, the AOJ should readjudicate the claims on the merits. If the benefits sought are not granted, the Veteran and his representative should be furnished a SSOC and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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 2014). _________________________________________________ DEBORAH W. SINGLETON 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).