Citation Nr: 18146514 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 16-24 695 DATE: October 31, 2018 ORDER Entitlement to service connection for a left shoulder degenerative joint disease is granted. FINDING OF FACT Resolving all reasonable doubt in favor of the Veteran, the Veteran’s current left shoulder is related to his in-service injury. CONCLUSION OF LAW The criteria for service connection for a left shoulder disability have been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from March 1967 to December 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of an October 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for a left shoulder disability The Veteran contends that his left shoulder disability, to include degenerative joint disease was incurred in service; namely an incident in or around August 1968 after lifting a heavy mail bag. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran’s service treatment records (STRs) note one complaint concerning the Veteran’s left shoulder. The Veteran was seen in October 1968 for complaints of on-going left shoulder pain following an injury two months prior. An October 1968 radiological study was noted to be “negative for osseous pathology”. At the Veteran’s October 1969 separation examination, he denied painful or trick shoulder or elbow, as well as any bone, joint or other deformity. The Veteran underwent a VA examination in October 2014. The Veteran reported a partial dislocation in August 1968 which was reset by another soldier. He relayed that he aggravated the injury with subsequent exercise which was intended to strengthen his shoulder. He stated that it had deteriorated over the years. He also confirmed a second left shoulder dislocation that self-reduced, which occurred 10 years after the initial injury. On examination, the examiner diagnosed left acromioclavicular degenerative joint disease. Following examination and review of the claims file, the examiner opined that the Veteran’s left shoulder injury was less likely than not incurred in or caused by the claimed in-service injury. He explained only that per the Veteran’s records dated March 1969 and October 1969, prior to and after the Veteran’s separation there was no documented left shoulder complaints and/or diagnosis. In addition, he reported no documented evidence of any on-going or chronic left shoulder complaints. However, it is unclear whether the examiner was referring strictly to the period prior to the Veteran’s separation from active duty, as the Veteran’s records are positive for diagnosed severe left shoulder degenerative joint disease. In a May 2016 office visit, the Veteran’s private orthopedic specialist, Dr. J.Z., noted the Veteran had a long history of left shoulder pain with current reports of pain, stiffness and instability. The provider noted the Veteran had been diagnosed with severe degenerative joint disease. He noted that the Veteran’s current problems were on a “more probable than not basis” correlated to his injury in the Army. In a separate May 2016 letter, Dr. J.Z. again noted the Veteran’s continued difficulties over the years with his left shoulder. He noted that he reviewed the Veteran’s military record and concluded that the Veteran’s left shoulder injury initially occurred in the Army and that it has progressively gotten worse over time. Upon review of the record, the Board notes that there are probative medical opinions in favor of and against the claim. After consideration of the competent, credible, and probative evidence, the Board finds the evidence is at least in equipoise as to whether the Veteran’s current left shoulder disability is related to the in-service shoulder injury. Accordingly, after resolving all doubt in the Veteran’s favor, the Board concludes that service connection for left shoulder degenerative joint disease is warranted. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Rachel Mamis