Citation Nr: 18149638 Decision Date: 11/14/18 Archive Date: 11/13/18 DOCKET NO. 16-41 254 DATE: November 14, 2018 REMANDED Entitlement to service connection for right shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1988 to September 2013. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of an August 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Veteran asserts that she has a right shoulder disability that is related to mandatory military workouts. Service treatment records (STRs) document a January 1988 complaint of a knot on the right shoulder. The Veteran related a two to three-day history of pain with use. The examiner observed a right shoulder lump. The Veteran was assessed as having a 1st degree separation. A January 1998 STR reflects a complaint of right shoulder pain. Post-service, the Veteran was afforded a VA examination in January 2014. The examiner opined that it was less likely than not that the Veteran’s right shoulder disability was related to service. The examiner explained that the Veteran had a diagnosis of remote AC joint sprain in 1988 without a history of trauma at that time. The examiner noted that upon current examination, the Veteran had pain over both AC joints, but normal motion and an otherwise normal exam. Her x-rays showed no significant arthritic changes to her AC joint and no abnormalities to the glenohumeral joints. The examiner concluded that “the Veteran’s remote AC joint sprain is not related to her current pain in both shoulders and she has relatively normal x-rays and examination results.” In February 2014, the RO obtained an additional VA opinion. The examiner stated that a careful review of the Veteran’s service records indicates that there is sufficient evidence in the Veteran’s service records to support onset of the Veteran’s shoulder pain while the Veteran was in the military service. The examiner referenced the Veteran’s January 1998 STR noting a complaint of right shoulder pain. X-rays taken during July 2015 VA treatment showed moderate bilateral acromioclavicular joint degenerative changes. An October 2015 private treatment record shows that the Veteran underwent right shoulder surgery, to include arthroscopic rotator cuff repair, distal clavicle excision, and subacromial decompression. The Board finds that the opinions of record are inadequate to decide the claim on appeal. In particular, the January 2014 VA examiner appears to suggest that because the Veteran’s January 2014 VA examination resulted in “relatively normal x-rays and examination” without significant arthritic changes to her AC joint and abnormalities to the glenohumeral joints of her right shoulder, the Veteran’s in-service right shoulder injury is not related to her current right shoulder pain. However, the Board notes that the Veteran has since undergone right shoulder surgery, to include arthroscopic rotator cuff repair, distal clavicle excision, and subacromial decompression. Furthermore, she has been diagnosed with moderate bilateral acromioclavicular joint degenerative changes. The Board also notes that the January 2014 VA examiner made no mention of the Veteran’s January 1998 complaint of right shoulder pain as seen in her STRs. Additionally, although the February 2014 VA examiner provided a positive opinion, the examiner did not provide any rationale for this conclusion. Inadequate medical examinations include examinations that contain only data and conclusions, do not provide an etiological opinion, are not based upon a review of medical records, or provide unsupported conclusions. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Due to the lack of supporting rationale, the Board concludes that the positive medical opinion by the February 2014 VA examiner is inadequate for resolving the claim, and thereby accorded no probative value in support of the claim. Nieves- Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124. In light of these deficiencies, the Board finds that a remand is necessary in order to obtain another VA examination and opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an examiner with appropriate expertise, preferably one who has not previously examined the Veteran in connection with this appeal, to obtain an opinion addressing the etiology of her right shoulder disability. The examiner must review the claims file, identify each right shoulder disorder present, and provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any right shoulder disorder identified is etiologically related to service, or was manifest within one year of separation from active service. The examiner must consider the Veteran’s reported right shoulder symptoms and injuries documented in her service records. The examination report must include a complete rationale for all opinions provided. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Gordon, Associate Counsel