Citation Nr: 18148713 Decision Date: 11/08/18 Archive Date: 11/07/18 DOCKET NO. 15-32 569 DATE: November 8, 2018 REMANDED 1. Service connection for right shoulder disorder is remanded. 2. Service connection neck disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1993 through November 2012. These matters come before the Board of Veteran’s Appeals (Board) on appeal from a February 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), denying service connection for both right shoulder and neck disorders. The Veteran presented testimony at a video hearing before the undersigned Veterans Law Judge in November 2016. A transcript of the hearing has been associated with the electronic claims file. Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303 (a). Service connection requires evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the condition incurred or aggravated by service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the present case, the Veteran has a current diagnosis of impingement syndrome of right shoulder, rotator cuff tear arthropathy of right shoulder and right shoulder pain (1/4/2017 Medical Treatment Record-Non-Government Facility, p. 4). The Veteran also has a current diagnosis of a neck disability, specifically, foraminal stenosis of cervical region and degenerative disc disease, cervical (1/4/2017 Medical Treatment Record-Non-Government Facility, pgs. 13-14). The Veteran’s STRs reveals a history of both right shoulder and neck treatment. The Veteran sought in-service treatment for his right shoulder in May 1996, receiving a diagnosis of right rotator cuff tear (6/11/2012 STR-Medical, p. 39). He was placed on a profile, directing him to refrain from lifting or pushups for 6 weeks (6/11/2012 STR-Medical, p. 129). In April 2008, he received a diagnosis of shoulder sprain rotator cuff (capsule) right (6/11/2012 STR-Medical, p. 31). In May 2008, the Veteran’s medical record notes right shoulder tendonitis and he received a provisional diagnosis of “subacromial supraspinatus impingement problem – right shoulder.” He was treated at that time with a subacromial injection (6/11/2012 STR-Medical, p. 26). He again sought treatment in August 2010 for right shoulder pain, diagnosed as “joint pain, localized in the shoulder: s/s consistent with supraspinatus impingement vs tendinopathy” and received physical therapy (6/11/2012 STR-Medical, pgs. 41 and 47-48). In September 2011, his medical record reflects a shoulder sprain that required physical therapy (6/11/2012 STR-Medical, pgs. 8-12). In October 2008, the Veteran sought treatment for a headache, mentioning neck pain: his “6th migraine in two month (sic.), had his helmet ripped off his head on a jump in August, has neck pain on and off since” (6/11/2012 STR-Medical, p. 20). The Veteran had an in-service CT scan of his cervical spine in November 2008, demonstrating “no evidence of a fracture or spondylolisthesis” and a “normal cervical spine” (6/11/2012 STR-Medical, p. 11). However, he was treated for neck pain in December 2009, and diagnosed with cervical spondylosis and segmental dysfunction of cervical region (6/11/2012 STR-Medical, pgs. 3-5). Further treatment for neck pain occurred in April 2010, and physical therapy was ordered (6/11/2012 STR-Medical, pgs. 81-82). A July 2012 VA examination made no diagnosis of either right shoulder or neck disability because there was “no pathology to render a diagnosis” (9/17/2012, C&P Exam, pgs. 13 and 36). The Veteran’s January 2107 records do not provide a medical opinion with regard to the etiology of either his right shoulder disorder or his neck disorder (1/4/2017 Medical Treatment Record-Non-Government Facility, p. 4). Accordingly, a VA medical opinion is necessary to determine the etiology of the Veteran’s right shoulder and neck disability. Accordingly, the case is remanded for the following action: 1. Obtain a VA medical opinion by a qualified VA examiner to determine the etiology of the Veteran’s right shoulder disability and neck disability. All pertinent evidence of record, including this remand, must be made available to, and reviewed by, the examiner. Review of the claims file should be noted in the examiner’s report. If the examiner determines that an additional examination is indicated, such examination should be scheduled. 2. The examiner should consider the in-service treatment of the Veteran’s right shoulder in his or her review. The examiner should specifically address the relationship, if any, between the current right shoulder diagnosis and the Veteran’s documented rotator cuff tear in 1996 (6/11/2012 STR-Medical, p. 39). 3. The examiner should consider the in-service treatment of the Veteran’s neck in his or her review. The examiner should specifically address the relationship, if any, between the Veteran’s current neck diagnosis with the October 2008 medical note regarding the Veteran’s reported neck injury during a jump, when his helmet was ripped off his head (6/11/2012 STR-Medical, p.20). 4. Following a review of the relevant records and an additional examination if indicated, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran's right shoulder disability and neck disability originated during or is otherwise related to his active service. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should explain why, and explain whether the lack of certainty is due to the limitations of medical or scientific knowledge or insufficient evidence. If due to insufficient evidence, the examiner should state what additional evidence, would be required to offer an opinion. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. A. Myers, Associate Counsel