Citation Nr: 18141581 Decision Date: 10/11/18 Archive Date: 10/10/18 DOCKET NO. 16-16 589 DATE: October 11, 2018 REMANDED Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1996 to March 2001, from October 2004 to January 2006, and from May 2009 to July 2010. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island. Entitlement to service connection for a left shoulder disability and a cervical spine disability is remanded. Although the Board regrets the additional delay, 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 claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2018). The Board first notes that the Veteran claims entitlement to service connection for a left shoulder disability and a cervical spine disability, which he contends had their onset in service. See June 2013 application for compensation. Pursuant to this claim, the Veteran was afforded VA examinations in March 2016, to assess the nature and etiology of both claimed disabilities. The Veteran’s shoulder examination reflects only that he reported pain, as well as flare ups. A diagnosis of left shoulder strain was rendered. Pertinently, the examiner opined that the Veteran’s left shoulder strain is less likely than not related to service. The supporting rationale for this conclusion was that there is “no evidence of any connection,” and “no clearly documented continuum of care from service until now.” The same examiner conducted the Veteran’s cervical spine examination. The examiner diagnosed a cervical strain disability, and the examination reflects only the Veteran’s complaints of pain and flare-ups. Pertinently, the examiner opined that the Veteran’s cervical strain is less likely than not related to service. The supporting rationale for this conclusion is similarly that there has been no evaluation since 1998, that there is “no evidence of any connection,” and “no clearly documented continuum of care from service until now.” These rationales are conclusory, and fail to explain why a “clearly documented continuum of care” is necessary to establish a causal relationship between the Veteran’s disabilities and service. For the left shoulder examination, while the examiner restates the request for an opinion relating to the Veteran’s documented service injury of December 2009, the in-service event was not discussed or even acknowledged. Similarly, the Veteran’s documented October 1999 neck trauma in service while playing football was neither discussed nor acknowledged in the cervical spine examination. Furthermore, the Veteran’s clearly documented complaints of severe, constant pain, and inability to lift anything over his shoulders, were not discussed by the examiner. In addition, the Board notes that service connection does not require a “clearly documented continuum of care” to be established. Rather, the burden of proof is that of equipoise – as likely as not – whilst also affording the Veteran the benefit of the doubt. When VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To the extent that a direct basis was discussed in the opinion, the VA examiner relied on the absence of documented treatment records and did not consider the Veteran’s lay statements regarding symptomatology. See Dalton v. Peake, 21 Vet. App. 23 (2007); See also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (2006) (noting that the VA examiner’s opinion, which relied on the absence of contemporaneous medical evidence, “failed to consider whether the lay statements presented sufficient evidence of the etiology of [the veteran’s] disability such that his claim of service connection could be proven”). Consequently, the Board finds that the Veteran must be afforded adequate VA examinations. The matters are REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any relevant outstanding treatment records, to include any VA and/or private treatment records. If any identified records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, afford the Veteran a VA examination by an examiner with appropriate expertise to determine the nature and etiology of his left shoulder strain. Any and all studies, tests, and evaluations that are deemed necessary by the examiner should be performed, including imaging studies. The claims folder, including a copy of this remand, must be reviewed by the examiner. The examiner must provide an opinion as to whether it is at least as likely as not (i.e. a probability of 50 percent or greater) that the Veteran’s left shoulder strain originated during, or is etiologically related to, active duty service. In rendering this opinion, the examiner must specifically comment on the Veteran’s March 2016 VA examination report, VA treatment records, STRs documenting shoulder complaints, and treatment for a December 2009 injury during active duty, as well as the Veteran’s lay statements of record. A complete rationale must be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. The examiner is advised that the Veteran is competent to report injuries and symptoms, and that his reports must be considered in formulating the requested opinions. If the Veteran’s reports are discounted, the examiner should provide a reason for doing so. 3. The Veteran must be afforded a VA examination by an examiner with appropriate expertise to determine the nature and etiology of his cervical strain. Any and all studies, tests, and evaluations that are deemed necessary by the examiner should be performed, including imaging studies. The claims folder, including a copy of this remand, should be reviewed by the examiner. The examiner must provide an opinion as to whether it is at least as likely as not (i.e. a probability of 50 percent or greater) that the Veteran’s cervical strain originated during, or is etiologically related to, active duty service. In rendering this opinion, the examiner must specifically comment on the Veteran’s March 2016 VA examination report, VA treatment records, STRs documenting shoulder complaints and treatment for an October 1999 football injury during active duty, and the Veteran’s lay statements of record. A complete rationale must be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. The examiner is advised that the Veteran is competent to report injuries and symptoms, and that his reports must be considered in formulating the requested opinions. If the Veteran’s reports are discounted, the examiner should provide a reason for doing so. CAROLINE B. FLEMING Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G.C., Associate Counsel