Citation Nr: 18150564 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 16-46 707A DATE: November 15, 2018 REMANDED Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a cervical spine (neck) disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the Marine Corps from October 1984 to October 1987. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2015 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. Right Shoulder and Cervical Spine (Neck) Disability The Board notes that VA must provide a medical examination or obtain a medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2), 38 C.F.R. § 3.159 (c)(4)(i). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, disease or injury is a low threshold. McLendon, 20 Vet. App. at 83. To date, the Veteran has not been afforded a VA examination in response to either his right shoulder injury claim or his cervical spine (neck) claim. A review of the of the Veteran’s private treatment reports from Healthsouth show treatment for rotator cuff tear tendinitis in January 2000. Treatment reports from Texas Neurosurgery, LLP show the Veteran reported neck pain in August 2014. Additionally, a Baylor Medical Center operative report indicates that the Veteran underwent surgery to have his C6-7 vertebrae fused. In a January 2017 Texas Neurosurgery, LLP treatment note the Veteran’s examiner indicated that the Veteran’s history of trauma to the cervical spine, heavy lifting, twisting, or bending could have caused a degenerative disease that could evolve into a situation that required the Veteran’s surgery; even if the history of the trauma was remote. The Veteran’s STRs do not indicate he experienced problems associated with these claimed disabilities during active duty; however, the Veteran has indicated that he experienced neck and shoulder pain, as well as shoulder dislocation, during his active duty service as a result of the equipment he had to carry as a field radio operator and a fall he experienced during a joint training mission in South Korea. The Veteran has also submitted lay “buddy” statements from two fellow Marines whom the Veteran served with. In one statement, the Veteran’s fellow service-member witnessed the Veteran’s shoulder “slip out of place” many times between 1986 to 1987. In the second statement another fellow service-member claims he witnessed the Veteran’s fall in 1987 during a training exercise in South Korea, and that after he fell the Veteran complained of both neck and shoulder pain. Based on the foregoing, the Board finds VA examinations and medical opinions are necessary to address these issues. On remand, relevant ongoing medical records should also be obtained. 38 U.S.C. § 5103A(c) (2012); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). The matters are REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Then, afford the Veteran a VA examination(s) by an examiner(s) with sufficient expertise to address the etiology of the Veteran’s claimed right shoulder and cervical spine (neck) disabilities. All pertinent evidence of the record must be made available to and reviewed by the examiner(s). Any indicated studies should be performed. Following a review of the relevant records and lay statements, the examiner(s) should state an opinion with respect to whether it is at least as likely as not (a 50 percent probability or greater) that any diagnosed right shoulder or cervical spine (neck) disabilities originated during the Veteran’s period of active service or are otherwise etiologically related to his active service, to specifically include as a result of his carrying heavy equipment as part of his occupational duties as a field radio operator and as a result of his fall during a 1987 training exercise in South Korea. The examiner(s) must provide a complete rationale for all proffered opinions. In this regard, the examiner(s) must discuss and consider the Veteran’s competent lay statements. If an examiner is unable to provide any required opinion, he or she should explain why. If an examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner(s) should identify the additional information that is needed. 3. Finally, undertake any other development determined to be warranted, and then readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, furnish to the Veteran and his representative a supplemental statement of the case and afford them the requisite opportunity to respond. Thereafter, if indicated, the case should be returned to the Board for further appellate action. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Gresham