Citation Nr: 18142941
Decision Date: 10/18/18	Archive Date: 10/17/18

DOCKET NO. 16-32 074
DATE:	October 18, 2018
REMANDED
Entitlement to service connection for a left shoulder disability is remanded.
REASONS FOR REMAND
The Veteran served on active duty in the United States Army from August 1970 to September 1970.  This matter comes before the Board from an March 2016 rating decision.  
1. Entitlement to service connection for a left shoulder disability is remanded.
The Veteran contends that he had a shoulder injury prior to service, but it had resolved upon entry and was re-injured when he slipped and fell on a pitched roof and dangled over the edge.  A July 1970 pre-induction examination noted the presence of a left shoulder disorder. Contemporaneous histories provided by the Veteran reference the presence of a scar and a previous dislocation.  
The Veteran’s service treatment records (STRs) show complaints of pain and limited range of motion with increased activity.  The STRs also indicate that the Veteran had a surgery on his left shoulder five months prior to service and that pins from this surgery were still in place.  Medical Board Proceedings recommended the Veteran be discharged based on pre-existing injuries to his left shoulder and left femur.
The Veteran contends that he still experiences issues related to his left shoulder that he attributes to his fall in-service.  There are no recent medical records in the file and the Veteran has not been afforded a VA examination. Accordingly, there is insufficient competent evidence in the file to decide the claim.  A VA examination is warranted to determine the etiology of the Veteran’s left shoulder condition.  McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 
The matter is REMANDED for the following action:
1.  Ask the Veteran to identify any VA or non-VA health care provide who has treated his left shoulder disorder since service discharge. Obtain the records identified by the Veteran.
2. Schedule the Veteran for a VA examination by an appropriate VA medical professional to determine the current nature and etiology of any left shoulder disability.  The claims file should be made available to the examiner. Based on review of the record, the VA examiner should provide an opinion that responds to the following: 
(a.) Identify/diagnose any disability of the left shoulder that presently exists or that has existed during the appeal period. 
(b.) State whether there is clear and unmistakable (undebatable) evidence that the Veteran had a disability of the left shoulder prior to active service.  The disability(ies) should be clearly identified and described. Discussion of the pertinent medical evidence of record would also be helpful.
(c.) If it is determined that he had a left shoulder disability that preexisted service, state whether there is clear and unmistakable evidence that the disability was not aggravated beyond its natural progression. Any such clear and unmistakable evidence must be identified. Consideration should be given to the Veteran’s report of reinjuring his shoulder. See May 2016 Notice of Disagreement.
(d.) For any left shoulder disability not found to have preexisted active service, provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that it had its onset during service or is otherwise related to the Veteran’s active service, to include the fall he has described.
(e.) The examiner report must include a complete rationale for all opinions expressed.
 
MICHAEL A. HERMAN
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	E. Rekowski, Associate Counsel