Citation Nr: 1756799 Decision Date: 12/08/17 Archive Date: 12/15/17 DOCKET NO. 12-14 480 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a bilateral shoulder disorder. 2. Entitlement to service connection for hypertension. (The issues of entitlement to service connection for headaches and an acquired psychiatric disorder have been the subjects of recent separate decisions.) WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Howell, Associate Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The Veteran served on active duty from December 1972 to December 1976. He has also served in the National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama (hereinafter Agency of Original Jurisdiction (AOJ)). In preparing to decide the issue on appeal, the Board has reviewed the contents of the Veteran's electronic files, including the Content Legacy Manager and Veterans Benefit Management System (VBMS) claims files, using Caseflow Reader. All records are now in these electronic systems. The Veteran testified at an April 2017 videoconference hearing before the undersigned. A transcript of those proceedings is associated with the Veteran's VBMS file. Although part of the Veteran's claim was initially limited to the question of entitlement to service connection for bilateral shoulder arthritis, the medical evidence reflects bilateral shoulder disorders in addition to arthritis. Therefore, the issue, as reflected on the title page of this decision, was broadened to include service connection for a bilateral shoulder disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 9 (2009). The appeal is REMANDED to the AOJ. VA will notify the Veteran if further action, on his part, is required. REMAND The Veteran seeks entitlement to service connection for a bilateral shoulder disorder and hypertension. As an initial matter, the Board notes that the Veteran served in the National Guard after active duty service, and the claims file contains an August 1986 treatment record referring to a possible shoulder injury. It does not appear that the AOJ has attempted to obtain active duty for training (ACDUTRA) or inactive duty training (INACDUTRA) service dates for the Veteran. On remand, the AOJ should attempt to obtain the Veteran's Master Military Pay Account (MMPA) if available and/or existing. The dates the Veteran was ordered into Federal service may be available from the Defense Finance and Accounting Service (DFAS) that could be used to verify the Veteran's various duty statuses through his MMPA. Additionally, the AOJ should specifically verify the Veteran's duty status in August 1986. The record also reflects there may be outstanding, relevant private medical records. In the Veteran's May 2012 substantive appeal, he indicated that he was diagnosed with arthritis in 1978. Additionally, May 2001 VA treatment records reflect that, prior to May 2001, the Veteran's hypertension had been treated by outside facilities. On remand, the AOJ should attempt to obtain both of these sets of private medical records. Finally, VA is obligated to provide a medical examination when the record contains competent evidence that a claimant has a current disability or symptoms of a current disability, the record indicates that a current disability or symptoms of a current disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). See also 38 C.F.R. § 3.159(c)(4). In this case, there is evidence that the Veteran has a bilateral shoulder disorder, including shoulder pain, left shoulder tendonitis, shoulder osteoarthritis, and a torn labrum in the left shoulder. See, e.g., August 2011, May 2011, May 2010, and September 2009 VA Treatment Records. He has also undergone a hemiarthroplasty of his right shoulder. See November 2014 VA Treatment Records. The Veteran served as a cannon crew member during service, and has testified that any bilateral shoulder disorder is the result of regularly carrying heavy packs and moving tank parts while in service. See, e.g., August 1999 Private Medical Records; May 2001 Veteran Statement; April 2017 Hearing Testimony. There is also evidence that the Veteran has a diagnosis of hypertension. See, e.g., February 2002 VA Treatment Records. While in service, the Veteran was treated for physiological orthostatic syncope, anemia, and hypotension. See October 1975 Service Treatment Records. The Veteran has not been afforded a VA examination for either of these claims. On remand, these VA examinations should be scheduled. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Associate with the claims file VA treatment records since February 2015. 2. With the help of the Veteran as necessary, attempt to obtain private medical records indicating a diagnosis of arthritis in 1978. Additionally, attempt to obtain any private medical records concerning treatment of hypertension prior to May 2001. All attempts to obtain such records should be documented in the claims file. 3. Take additional action to verify the dates of the Veteran's ACDUTRA and INACDUTRA and any other type of National Guard service first by contacting the Defense Finance and Accounting Service (DFAS) and requesting the Veteran's Master Military Pay Account (MMPA). The AOJ must verify the Veteran's duty status in August 1986 4. After any additional documents are obtained and associated with the electronic claims file, schedule the Veteran for a VA examination regarding the claim for service connection for a bilateral shoulder disorder. The examiner must review the Veteran's Legacy Content Manager and VBMS files. Following examination and review of the claims folder, the examiner should identify all current bilateral shoulder disorders. For any current diagnosis, the examiner should opine as to whether it is at least as likely as not (i.e., a 50 percent or greater possibility) that the disorder had its onset in service or is causally or etiologically related to the Veteran's military service. In rendering the opinion, the examiner is requested to consider the following: * The Veteran's credible statements and testimony that he carried heavy packs and moved tank parts while serving as a cannon crew member in service; * August 1986 service treatment records reflecting treatment for a shoulder problem; and * Treatment records reflecting current shoulder problems including shoulder pain, left shoulder tendonitis, shoulder osteoarthritis, a torn labrum in the left shoulder, and a right shoulder hemiarthroplasty. (See, e.g., November 2014, August 2011, May 2011, May 2010, and September 2009 VA Treatment Records.) The examiner must provide a comprehensive report including complete rationales for all conclusions reached. 5. After any additional documents are obtained and associated with the electronic claims file, schedule the Veteran for a VA examination regarding the claim for service connection for a bilateral shoulder disorder. The examiner must review the Veteran's Legacy Content Manager and VBMS files. Following examination and review of the claims folder, the examiner should opine as to whether it is at least as likely as not (i.e., a 50 percent or greater possibility) that the Veteran's hypertension had its onset in service or is causally or etiologically related to the Veteran's military service. In rendering the opinion, the examiner is requested to consider the October 1975 service treatment records reflecting treatment for physiological orthostatic syncope, anemia, and hypotension. The examiner must provide a comprehensive report including complete rationales for all conclusions reached. 6. After completing the actions detailed above, readjudicate the claims remaining on appeal. If any benefits are not granted to Veteran's satisfaction, 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. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. See 38 U.S.C. §§ 5109B, 7112. _________________________________________________ T. MAINELLI Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), 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)(7).