Citation Nr: 1615768 Decision Date: 04/19/16 Archive Date: 04/26/16 DOCKET NO. 14-30 249 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for a right shoulder disorder, to include as secondary to the service-connected left knee disorder. REPRESENTATION Veteran represented by: Virginia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Sara Schinnerer, Counsel INTRODUCTION The Veteran served on active duty from November 1966 to October 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office in Roanoke, Virginia (RO). The Veteran's claim of entitlement to service connection for a left shoulder disorder has been recharacterized as a claim of entitlement to service connection for a right shoulder disorder based upon his testimony before the Board in December 2015. REMAND The Veteran contends that his current right shoulder disorder is due to his service-connected left knee disorder. In this regard, during a December 2015 hearing before the Board, the Veteran asserted that in February 2011 he injured his right shoulder as a result of a fall associated with his left knee. Specifically, he stated that while at his home, he and his grandson, as well as a contractor rebuilt his deck. The Veteran further stated that when they carried a six by six, sixteen foot long board that was approximately 200 pounds, his left knee gave out and he fell and landed on his right shoulder. Moreover, in an April 2013 statement, W.S., the Veteran's contractor, corroborated the Veteran's account of the right shoulder injury. In addition, VA outpatient treatment records dated in November 2011 through 2014 reflect diagnoses of osteoarthritis of the right acromioclavicular joint, as well as a disorder of the bursae and tendons in the right shoulder region. As the Veteran has not been afforded a VA examination in connection with this issue, the case must be remanded for such, as well as an opinion addressing whether the Veteran's current right shoulder disorder(s) is related to his active service, or caused or aggravated by the service-connected left knee disorder. 38 U.S.C.A. § 5103A(d)(2) (West 2014); 38 C.F.R. § 3.159(c)(4)(i) (2015); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, as the Veteran receives ongoing treatment from the VA Medical Center in Salem, Virginia, the RO must also obtain VA outpatient treatment records from such facility from December 2015 to the present. 38 C.F.R. § 3.159(c)(2). Accordingly, the case is remanded for the following actions: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. Regardless of the Veteran's response, the RO must obtain and associate with the claims file all of the Veteran's pertinent VA treatment records, to include records from the VA Medical Center in Salem, Virginia, dated from December 2015 to the present. When requesting records not in the custody of a Federal department or agency, such as private treatment records, the RO must make an initial request for the records and at least one follow-up request if the records are not received or a response that records do not exist is not received. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. Upon completion of the above development, the Veteran must be afforded an appropriate VA examination to determine whether any right shoulder disorder found or previously diagnosed is related to his active service, or the service-connected left knee disorder. The electronic claims file, must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. Any indicated diagnostic tests and studies must be accomplished. All pertinent symptomatology and findings must be reported in detail. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must provide an opinion as to whether any previously or currently diagnosed right shoulder disorder, to include osteoarthritis of the right acromioclavicular joint and a disorder of the bursae and tendons of the right shoulder region is related to his military service, or is due to or aggravated by his service-connected left knee disorder. A complete rationale for all opinions must be provided. If the examiner cannot provide a requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. The RO must notify the Veteran that it is his responsibility to report for any examination scheduled, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2015). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained and associated with the Veteran's claims file that shows that notice scheduling the examination was sent to his last known address. Documentation must be also be obtained and associated with the Veteran's electronic claims file demonstrating any notice that was sent was returned as undeliverable. 4. The medical report must be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the RO must implement corrective procedures. 5. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim for entitlement to service-connection for a right shoulder disorder must be adjudicated. If the benefit remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD 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).