Citation Nr: 1620840 Decision Date: 05/24/16 Archive Date: 06/02/16 DOCKET NO. 12-00 294 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for right shoulder arthritis with rotator cuff tear and labral injury. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. Miller, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1980 to August 1984, May 1990 to December 2001, and July 2002 to June 2003. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. In that decision, the RO, inter alia, denied service connection for a right shoulder disability. FINDING OF FACT The evidence is at least evenly balanced as to whether right shoulder glenohumeral arthritis with rotator cuff tear and labral injury is related to active service. CONCLUSION OF LAW With reasonable doubt resolved in favor of the Veteran, right shoulder glenohumeral arthritis with rotator cuff tear and labral injury was incurred during active service. 38 U.S.C.A. §§ 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service--the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). To make these determinations, the Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding any material issue, reasonable doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. When all of the evidence is assembled, VA must determine whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim will be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54-55 (1990); Alemany v. Brown, 9 Vet. App. 518 (1996). During service, the Veteran was diagnosed with a grade 1 acromioclavicular joint separation, in March 1981. A record from March 7, 1981 noted a possible rotator cuff tear, though a later record from two days later cast doubt on that diagnosis. An x-ray from March 1981 was also negative. The Veteran was diagnosed with right shoulder glenohumeral arthritis at his December 2011 VA examination, and a torn rotator cuff and superior labral injury at his April 2012 examination, so the salient question is whether either of his right shoulder disabilities are traceable to this period of military service. The Board notes that both of the etiology opinions provided by VA were negative. The December 2011 examiner stated that the Veteran's right shoulder glenohumeral arthritis is not due to the Veteran's injury in service, as a grade 1 acromioclavicular joint separation is just a contusion of the joint without any ligamentous change, and that contusions are soft tissue injuries that do not cause, contribute to, or enhance the progression of arthritis. There was no evidence of damage to the structure of the shoulder joint that would lead to or enhance arthritic changes. The December 2012 examiner opined that the Veteran's torn rotator cuff and superior labral injury is less likely as not the result of his military service, as the Veteran's injury in service was an acute contusion and self-limited injury that resolves over time. The examiner also noted that the x-ray conducted in service was normal, and that an x-ray from 2008 found only minimal degenerative changes consistent with age. The examiner stated that the Veteran's torn rotator cuff and superior labral injury was diagnosed in 2012, more than 30 years after service, and that there is no reasonable medical rationale for a causal relationship from his contusion in service causing his shoulder disability. In contrast, there are two private positive nexus opinions. The Veteran first provided a February 2012 opinion from Dr. W.S., an orthopedic physician. He noted that the Veteran injured his shoulder in March 1981, and may have had a torn rotator cuff. Dr. W.S. noted the Veteran's statements that the shoulder has never been normal since the injury, and that he has pain that radiates down his arm. Radiology reports noted moderate acromioclavicular degenerate changes with some joint space narrowing. He diagnosed the Veteran with chronic right shoulder pain secondary to an old military injury, and that his symptoms are consistent with a labral, biceps tendon, or subscapularis problem. More recently, the Veteran has provided a copy of a December 2013 opinion from Dr. C.N.B, a neuro-radiologist. He opined that there is a 90 percent level of probability that the Veteran's current right shoulder disability is due to in service injury. In support, he noted that the Veteran entered service without any diagnosed issues, was treated for the acromioclavicular joint separation and possible rotator cuff tear; has now been diagnosed with a right shoulder rotator cuff tear; February 2012 radiology reports document acromioclavicular degeneration, decreased acromioclavicular distance, acromial impingement, and subchrondal cystic changes that are consistent with long standing rotator cuff tear; lay statements documenting continuous and persistent symptomology; the Veteran's medical records do not support another more likely cause for his rotator tuff tear and osteoarthritis; the prior VA examinations did not have the benefit of the MRI scan documenting the rotator cuff injury; and that the time lag between injury in service and current pathology is consistent with known medical principles and the natural history of the disease. He also noted that the VA examiner was incorrect in stating that contusions are soft tissue injuries that do not have a relation to arthritis, and that the VA opinions are inconsistent with the Veteran's radiology reports. With respect to evaluating the medical evidence, generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999). See also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The above evidence reflects that the opinion from Dr. C.N.B. was thorough and provided a lengthy discussion of the Veteran's symptoms and history, and detailed the rationale for the positive opinion. While the VA opinions were negative, and also considered the Veteran's history and provided rationale, when comparing them and the report from Dr. C.N.B., the evidence as to whether the Veteran's right shoulder disability is related to his right shoulder injury in service is at least evenly balanced. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for the diagnosed right shoulder arthritis with rotator cuff tear and labral injury is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for right shoulder arthritis with rotator cuff tear and labral injury is granted. ____________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs