Citation Nr: 18143227 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 15-13 044 DATE: October 18, 2018 REMANDED 1. Entitlement to service connection for a left shoulder disability is remanded. 2. Entitlement to service connection for a right shoulder disability is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from October 1994 to August 2003, and from September 2008 to February 2010, with additional Reserve service. There matters are before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision. 1., 2. Entitlement to service connection for left and right shoulder disabilities is remanded. A review of the record found that further development is needed for VA to fulfill its duty to assist mandated under the VCAA. The Veteran’s service personnel records reflect he was a parachutist in service; his DD-214s reflect that he was awarded a Combat Infantryman Badge and a Parachutist Badge. It is not in dispute (and was conceded by the undersigned at the June 2018 Board hearing) that in the course of his duties he sustained bilateral shoulder trauma (from parachutes deploying). His service treatment records (STRs) include a December 2009 post-deployment health assessment (PDHA) which notes the Veteran’s report of “insidious onset” of shoulder pain (and that conservative therapy failed) during his deployment to Iraq. An STR of the same date reflects a provisional diagnosis of rotator cuff syndrome. On December 4, 2013 VA shoulder examination, bilateral shoulder tendonitis was diagnosed. In January 2014 (after the December 2013 examination), an MRI showed rotator cuff tears in both shoulders, as well as right long biceps tenosynovitis and tearing. As the December 2013 examination report did not encompass consideration of these findings, and apparently does not reflect the current status of both shoulders, it is inadequate for rating purposes. [The Board also finds the report inadequate as the rationale for the opinion provided is based on the inaccurate factual premise that there is no evidence of shoulder injury during active duty or chronicity of a shoulder condition during service; as noted above, a December 2009 PDHA notes complaints of bilateral shoulder pain and an assessment of rotator cuff syndrome. Furthermore, the opinion appears limited to consideration of parachute jumps as an etiological factor for the development of shoulder disability; the Veteran has also expressed his belief that his shoulder disabilities may be related to carrying a heavy rucksack and wearing body armor. See July 2014 statement.] Consequently, another orthopedic examination to ascertain the nature and etiology of the Veteran’s left and right shoulder disabilities is necessary. As the case must be remanded for additional development anyway, the Veteran will have the opportunity to submit (or identify for VA to obtain) any outstanding (i.e., those not already in the record) private treatment records pertaining to his right and left shoulder disabilities. Records of any VA treatment for his right and left shoulders since February 2015 (the date of the most recent VA treatment record associated to the record) may contain pertinent evidence, are constructively of record, and must be secured. The matters are REMANDED for the following: 1. Secure for the record all updated records of VA evaluations and treatment the Veteran has received for his left and right shoulder disabilities since February 2015 (when the most recent VA treatment records associated with the record are dated). Ask the Veteran to provide identifying information regarding all private evaluations or treatment he has received for his shoulders, and to submit authorizations for VA to secure for the record complete outstanding clinical records from all providers identified. Obtain those records. 2. After the development requested above is completed, arrange for an orthopedic examination of the Veteran to determine the nature and likely etiology of his right and left shoulder disabilities. The Veteran’s entire record (to include this remand, the December 2013 VA shoulder examination report, the January 2014 MRI report, and any newly obtained records) must be reviewed by the examiner in conjunction with the examination. On examination/interview of the Veteran and review of his record, the examiner should provide opinions that respond to the following: (a) Identify (by diagnosis) each right and left shoulder disability entity found (or shown by the record during the pendency of this claim). [If bilateral rotator cuff tears or tendonitis are not diagnosed, please reconcile such finding with the diagnoses noted above.] (b) Identify the likely etiology for each right and left shoulder disability entity diagnosed. Specifically, is it at least as likely as not (a 50% or better probability) that the disability was incurred or aggravated during the Veteran’s active service, to include his reports of parachuting, carrying a heavy ruck sack, and wearing body armor in service? The examiner must include rationale with all opinions. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Dupont, Associate Counsel