Citation Nr: 18146211 Decision Date: 10/31/18 Archive Date: 10/30/18 DOCKET NO. 14-35 460 DATE: October 31, 2018 REMANDED Entitlement to service connection for a left shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty for training from January 1982 to March 1982, and on active duty from January 2003 to January 2008, and from May 2008 to September 2011. This matter comes before the Board of Veterans’ Appeals (Board) from a January 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that denied the Veteran’s claim of entitlement to service connection for a left shoulder disability. While the Board regrets further delay, the Veteran’s claim must be remanded for further development. Before adjudicating the claim for service connection, VA’s duty to assist in developing the claim must be satisfied. Here, this duty involves offering an examination to determine the nature and likely etiology of the Veteran’s claimed left shoulder disability. See 38 U.S.C. § 5103A; McLendon v. Nicholson, 20 Vet. App. 79 (2006). To date, the Veteran has not been afforded such an examination. While the Veteran’s service treatment records (STRs) contain a history of right shoulder impingement for which the Veteran is currently service-connected, a left shoulder disability (specifically, tendinitis) was not diagnosed until November 2012, 14 months after her service discharge. She underwent arthroscopic surgery on her left rotator cuff in July 2013. Several lay statements, including buddy statements, note the Veteran’s assertion that, despite her STRs noting only a right shoulder disability, she had ongoing bilateral shoulder pain during her military service due to physical fitness training. In the November 2012 VA treatment record that contains the first diagnosis of left shoulder tendinitis, the Veteran reported a longstanding history of low level left shoulder pain that was never severe enough to limit function, but noticeably present for “several years.” Given the Veteran’s currently service-connected right shoulder disability, her diagnosis of a similar left shoulder disability 14 months after service, and competent reports of longstanding bilateral shoulder pain that began during service, the Board finds that a VA examination is needed to obtain a medical opinion on the nature and etiology of the Veteran’s current left shoulder disability. The matter is REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to her claim. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, the Veteran should be afforded a VA examination to determine the nature of any left shoulder disability, and to obtain an opinion as to whether such is related to service. The claims file should be reviewed by the examiner. All necessary tests should be conducted and the results reported. The examiner should elicit a full history from the Veteran and consider the lay statements of record, including buddy statements submitted in March 2014. It is noted that the Veteran is competent to attest to factual matters of which she has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to the following: a) Whether it is at least as likely as not (50 percent probability or greater) that any current disability of the left shoulder is related to an in-service injury, event, or disease. b) Whether it is at least as likely as not (50 percent probability or greater) that any left shoulder disability was (i) caused by or (ii) aggravated (i.e., worsened beyond its natural progression) by the Veteran’s service-connected right shoulder disability. The Board directs the examiner’s attention to the initial diagnosis of a left shoulder disability in November 2012, 14 months after service discharge. A rationale for all opinions expressed should be provided, including any alternative etiologies for the Veteran’s left shoulder disability, as the Board is precluded from making any medical findings. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Scarduzio, Associate Counsel