Citation Nr: 1804345 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 10-42 718 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a bilateral shoulder disorder. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for shortness of breath. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran had active duty service from September 2002 to September 2008, with service in the Southwest Asia Theater of Operations. These matters come to the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The claims were remanded by the Board in June 2015 in order to schedule the Veteran for a requested hearing. The Veteran presented testimony at a personal hearing before the undersigned Veterans Law Judge in October 2017. A transcript is of record. The issues of entitlement to service connection for hypertension and shortness of breath are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The Board resolves reasonable doubt in the Veteran's favor and finds that service connection for a bilateral shoulder disorder, diagnosed as bilateral shoulder strain, is warranted. CONCLUSION OF LAW The requirements for establishing service connection for a bilateral shoulder disorder have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran claims service connection for a bilateral shoulder disorder. He testified that his shoulders began hurting in service as a result of upper body strength exercises, to include pushups and overhand arm claps, holding weapons, and lifting artillery. He further testified that he went to sick call many times and was given anti-inflammatory medication and that his shoulders have had pain since then. Service treatment records do not document any complaint of, or treatment for, shoulder problems; however, the Veteran is competent to report shoulder pain in service and the Board finds this assertion to be credible. The Board also finds the Veteran's competent assertion that he has had bilateral shoulder pain since service to be credible. The Veteran underwent a VA examination in March 2009. He reported a bilateral shoulder condition that onset in 2003-2004. He said there was a burning sensation deep in the left shoulder with certain movements and that both shoulders hurt with pushups and lift ups, which he tried not to do anymore. The Veteran denied a prior history of trauma to the shoulders. The examiner noted that a December 2008 VA treatment record noted bilateral shoulder arthralgia. Following physical examination, which revealed objective evidence of bilateral shoulder pain with motion, the Veteran was diagnosed with bilateral shoulder strain. No opinion on etiology was provided. Given the Veteran's competent and credible assertions that he experienced bilateral shoulder pain in service and that the pain has continued since then, and in light of the objective evidence of bilateral shoulder pain with motion during the March 2009 VA examination and the diagnosis of bilateral shoulder strain provided at that time, which was approximately six months after the Veteran's discharge from service, the Board resolves reasonable doubt in the Veteran's favor and finds that service connection for a bilateral shoulder strain is warranted. ORDER Service connection for bilateral shoulder strain is granted. REMAND It appears that there are outstanding VA treatment records. On remand, the Veteran's complete record of treatment from the VA Medical Center (VAMC) in Miami dated prior to October 2016 must be obtained. Records from the VAMC in Miami that are of record indicate that the Veteran was scheduled for a pulmonary disease appointment with a community care provider through the VA Choice program in August 2017. Records associated with this appointment must be obtained on remand. The Veteran was diagnosed with hypertension during a March 2009 VA examination, but no opinion regarding its etiology was provided, and the examiner indicated that no in-service blood pressure readings were found. Review of the medical evidence of record indicates that the Veteran had several elevated blood pressure readings in service, but was never diagnosed with hypertension. Post-service records also show several elevated blood pressure readings but no diagnosis of or treatment for hypertension. Another VA examination is needed on remand. During the March 2009 VA examination, no objective or subjective evidence of shortness of breath after was found, and he reported that he had not experienced shortness of breath since losing weight. In October 2017, however, he testified that he continued to experience problems with shortness of breath. Given that the Veteran was scheduled for a pulmonary disease appointment through VA Choice and had service in the Southwest Asia Theater of Operations, another VA examination is needed on remand. The Veteran is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case. Moreover, the consequences of failing to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655 (2017). Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's complete record of treatment from the Miami VAMC dated prior to October 2016. 2. Obtain records associated with an August 2017 pulmonary disease appointment with a community care provider through the VA Choice program. If a release form is needed to request such records, the Veteran should be asked to complete such form. 3. After the above has been completed to the extent possible and available records have been associated with the claim file, schedule the Veteran for a VA hypertension examination to clarify whether the Veteran has hypertension and to obtain an opinion as to whether any diagnosed hypertension is related to service. All indicated tests should be conducted and the results reported. The claims file must be reviewed in conjunction with the examination. The examiner should indicate whether it is at least as likely as not (50 percent probability or greater) that any currently or previously diagnosed hypertension arose in service or is etiologically related to service, to include the elevated blood pressure readings documented in service in March 2008 (130/93) and April 2008 (142/98). The discussion should also include reference to the post-service elevated blood pressure readings documented during the March 2009 VA examination (during which the Veteran was diagnosed with hypertension) and sporadically since discharge in the available VA records (December 2008 (135/95), April 2011 (135/91), January 2012 (122/93), and March 2017 (132/92)). The examiner must provide a rationale for the conclusions reached. 4. Schedule the Veteran for a VA respiratory conditions examination to determine the current nature of any condition manifested by shortness of breath and to obtain an opinion as to whether any current condition manifested by shortness of breath is related to service. All indicated tests should be conducted and the results reported. The claims file must be reviewed in conjunction with the examination. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent probability or greater) that any diagnosed respiratory disorder had its onset during active service or is otherwise related to service, to include the Veteran's report of difficulty breathing in a March 2007 post-deployment assessment; his complaint of shortness of breath made in April 2008; and the right lung base findings on chest x-ray in April 2008 and June 2008. The examiner must provide a rationale for the conclusions reached. If the examiner finds the Veteran does not suffer from a diagnosed respiratory disorder, the examiner should indicate whether there are objective signs or symptoms of shortness of breath that represent an undiagnosed illness associated with the Veteran's service in the Southwest Asia Theater of Operations. The examiner must provide a rationale for the conclusions reached. 5. After undertaking the development above and any additional development deemed necessary, the Veteran's claims should be readjudicated, with consideration of all evidence associated with the record since the August 2010 statement of the case was issued. If any benefit sought on appeal remains denied, the appellant and his representative should be furnished a supplemental statement of the case and be given an appropriate period to respond thereto before the case is returned to the Board, if in order. The appellant 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. The law requires that all claims that are remanded by the Board 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. §§ 5109B, 7112 (2012). ______________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs