Citation Nr: 18144826 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 13-02 109 DATE: October 25, 2018 REMANDED Entitlement to service connection for a right shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from November 1967 to May 1971. This matter comes before the Board of Veterans’ Appeals (Board) from an April 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2017, the Board remanded the matter for additional evidentiary development. Following evidentiary development, the VA Appeals Management Center continued the previous denial in an October 2017 supplemental statement of the case. The claims file has been returned to the Board for further appellate proceedings. Entitlement to service connection for a right shoulder disability The Veteran contends that he injured his right shoulder in basic training for which he underwent surgery. He claims that he has had ongoing right shoulder pain since that time. As detailed in the Board’s July 2017 remand, the Veteran’s service treatment records reflect that right shoulder bursitis was noted at the time of his October 1967 service entrance medical examination. In-service treatment records show that in July 1968, the Veteran was hospitalized in connection with his complaints of right shoulder pain. He reported that approximately one year prior, he began to notice intermittent pain in the right shoulder; approximately three months prior, however, the pain became more insistent and was aggravated when his shoulder was struck. During hospitalization, the Veteran underwent an excisional biopsy of probably an osteoid osteoma of the right humerus. It does not appear that the biopsy results are available. In connection with his claim of service connection for a right shoulder disability, the Veteran was afforded a VA examination in March 2012. The examiner, a nurse practitioner, opined that the Veteran’s current right shoulder disability, degenerative changes with “probable” chronic rotator cuff degeneration, was less likely than not incurred in or caused by the reported in-service right shoulder injury. The examiner noted that this was because there was no evidence of a rotator cuff tear in service or any additional soft tissue injury. The examiner further indicated that recent x-rays showed age-related, normal biologic degenerative arthritis and rotator cuff degeneration of both shoulders. The examiner indicated that while there was current evidence of spurring which would be characteristic of arthritis, there was no current evidence of bursitis or osteoma on current examination, which were the diagnoses during active service. The examiner then opined that the Veteran’s right shoulder disability clearly and unmistakably existed prior to service and was less likely aggravated beyond its natural progression during the Veteran’s period of service. A rationale for this opinion was not provided. In July 2017, the Board remanded the matter, finding that the March 2012 VA examination was inadequate. The Board noted that there were two potential theories of entitlement to service connection for the Veteran’s right shoulder disability. The first theory of entitlement was that the Veteran’s current right shoulder disability is related to his right shoulder injury during basic training. The second theory of entitlement is that the Veteran’s current right shoulder disability is the result of an aggravation of his preexisting right shoulder disability. The Board found that the March 2012 examiner did not adequately consider both theories of entitlement and had impermissibly ignored the Veteran’s lay evidence of the in-service injury and continuing symptoms thereafter in providing the opinion. Pursuant to the Board’s remand instructions, the Veteran underwent another VA medical examination in September 2017. The examiner, a physician, acknowledged that the Veteran had undergone surgery in service but concluded that the Veteran’s current right shoulder disability, degenerative arthritis and possible rotator cuff degeneration, was most probably due to aging and the Veteran’s lifelong work of manual labor as there was “no documentation” or “medical records” documenting post-service problems with the right shoulder for at least 40 years after service when VA records revealed a “possible” rotator cuff tear and arthritic degeneration. The examiner further determined that the Veteran’s current right shoulder disability was not an aggravation of the preexisting osteoid osteoma (misdiagnosed as bursitis) because, although the Veteran underwent surgery in service, “there is no mention of any right shoulder pain or other symptoms on the discharge physical examination” and “[r]otator cuff tear and arthritis degeneration did not begin until over 40 years after discharge from the military.” Unfortunately, the Board finds that the September 2017 examination is inadequate. First, the examiner diagnosed the Veteran as having possible rotator cuff tear and arthritic degeneration. She noted that although the Veteran had reported a history of having undergone an MRI at the Salisbury VA Medical Center which showed a possible rotator cuff tear and arthritis, the results of the study were not available for review. The Board’s review of the record, however, indicates that it contains the results of a November 2012 MRI at the Salisbury VAMC which showed severe osteoarthritis with effusion, labral degeneration and a paralabral cyst suggesting a labral tear; a complete tear of the long head of the biceps tendon; and complete tears of the supraspinatus and infraspinatus tendons with retraction and muscular atrophy. Given the examiner’s failure to review these findings, her conclusion that the Veteran’s arthritis and “possible” rotator cuff pathology represented normal aging is of limited probative value. In addition, the examiner’s conclusion that the current right shoulder disability is not related to service because there are no records documenting shoulder problems after service is of little probative value. The U.S. Court of Appeals for Veterans Claims (Court) has made clear that “[s]ymptoms, not treatment, are the essence of any evidence of continuity of symptomatology.” Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). As set forth above, the Veteran has reported that he has had right shoulder symptoms since service. Thus, the matter is REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran’s current right shoulder disability. After examining the record, the clinician should: (a) Delineate all of the Veteran’s current right shoulder disabilities, to include the pathology identified on the November 2012 MRI performed at the Salisbury VAMC. (b) For each right shoulder disability identified, state whether it is at least as likely as not related to the Veteran’s active service including: (i) The Veteran’s in-service reports of right shoulder pain. (ii) The right shoulder injury the Veteran sustained in during active duty; and (iii) Aggravation during service of the preexisting right shoulder disability which was identified as bursitis at the October 1967 enlistment examination. (c) For each right shoulder disability identified, the clinician should also provide an opinion as to whether such disability is as likely as not a residual of the Veteran’s July 1968 right shoulder surgery. Specifically, the examiner should address whether the current disability condition is the result of the usual effects of ameliorative surgery. The clinician must provide a rationale for the opinions provided. In providing the rationale, he or she should reference the relevant evidence of record, to include the Veteran’s reports that he experienced shoulder pain since service. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Yun, Associate Counsel