Citation Nr: 18144458 Decision Date: 10/24/18 Archive Date: 10/24/18 DOCKET NO. 15-45 557 DATE: October 24, 2018 REMANDED Entitlement to service connection for a left shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1981 to November 1984. He also apparently had a prior period of active service of approximately two years and nine months, the dates of which have not been confirmed. This matter comes before the Board of Veterans’ Appeals (Board) from a November 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for a left shoulder disability is remanded. The Veteran contends that he injured his left shoulder during service. He has reported that he initially injured the shoulder during a drill at Fort Jackson, South Carolina in basic training in 1979. The RO has noted that the Veteran served on active duty from November 1981 to November 1984. His DD 214 for that period of service shows prior active service of approximately two years and nine months; however, no DD 214 for the earlier period of service is of record. Nor does it appear that the complete service treatment records for the earlier period have been obtained. Documentation of the earlier period of service and a request for complete service treatment and personnel records is warranted. Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). A VA examination of the Veteran’s left shoulder was conducted in September 2013. The examiner diagnosed post-traumatic deformity of the left distal clavicle. The examiner stated that the only reference to a left shoulder problem in the service treatment records was a negative X-ray on October 24, 1983, after left shoulder pain following a motor vehicle accident. The examiner indicated it was thus less likely than not that a current left shoulder disability was related to military service. The Board notes that the service treatment records contain several other references to left shoulder pain/injuries. The Veteran was seen on October 11, 1983 after suffering a left shoulder injury playing football on October 6, 1983. X-ray was within normal limits; an AC strain/contusion was noted. An October 11, 1983 orthopedic treatment record noted that the Veteran’s left AC joint had “an old appearing chronic type of dislocation, with no significant displacement on weightbearing.” On October 27, 1983 the Veteran was noted to have been in a motor vehicle accident the previous night, with complaints including left shoulder pain. In January 1984 the Veteran was seen with complaint of pain in the shoulders. Thus, the Board finds that the September 2013 VA physician’s opinion was based in part on an inaccurate history, and this opinion is inadequate for adjudication purposes. See Barr, 21 Vet. App. at 311-12. Another examination is necessary. The case is remanded for the following action: 1. Obtain the DD 214 pertaining to the Veteran’s period of active duty prior to November 1981 as well as all service treatment and personnel records from such period of active service. 2. Following the above, return the file to the September 2013 VA examiner for an addendum opinion. If that examiner is unavailable, then the file should be reviewed by clinician with sufficient expertise to determine the nature and etiology of the Veteran’s claimed left shoulder disorder. If the providing examiner determines that a clinical evaluation is necessary in order to provide the opinions requested, then one should be provided and all indicated tests and studies performed. The electronic claims file must be made available to the examiner. After review of the evidence of record, and with consideration of the Veteran’s statements, the examiner must provide an opinion as to whether any current or previously diagnosed left shoulder disorder is related to the Veteran’s military service, to include the left shoulder injuries noted from football injury and motor vehicle accident in October 1983, as well as any earlier left shoulder injury that may be shown in additional service treatment records obtained from the development requested above. The examiner must provide a complete rationale for all opinions expressed. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. G. Mazzucchelli, Counsel