Citation Nr: 18153366 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 15-16 945 DATE: November 27, 2018 REMANDED Entitlement to service connection for a right shoulder disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1976 to August 1981. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. At such time, the record was held open for 90 days for the submission of new evidence, which received in May 2018. 38 U.S.C. § 7105(e)(1). In accordance with his request, the Veteran was provided with a copy of the April 2018 Board hearing transcript in September 2018. In October 2018, he moved to correct such transcript, which was granted in November 2018. 1. Entitlement to service connection for a right shoulder disorder. The Veteran contends that his current right shoulder disorder is related to an injury he sustained while using the monkey bars during basic training. While the Veteran’s service treatment records (STRs) mostly reference tendonitis of the left shoulder, for which he is service-connected, a July 1978 record reflects that, while he was seen for complaints of increased pain in the left shoulder, objective examination revealed pain on abduction and palpation on the anterior aspect of the right shoulder, and supraspinous tendonitis was diagnosed. In this regard, it was noted that the Veteran had sustained an injury playing basketball. Similarly, based on complaints referable to both shoulders, an X-ray of the bilateral shoulders was requested in September 1979; however, there was no evidence of acromioclavicular (AC) separation and no abnormal findings referable to the right shoulder were noted. The Veteran underwent a VA examination to determine the nature and etiology of his right shoulder disorder in February 2013. At such time, the examiner reviewed the record, to include the aforementioned STRs, interviewed the Veteran, and conducted a physical examination with diagnostic testing, and diagnosed rotator cuff tendonitis with arthritis. However, he opined that such disorder was not caused by, a result of, or aggravated by the Veteran’s military service. In this regard, the examiner explained that, while the Veteran established a pattern of chronicity of documented left shoulder complaints in service, which would be expected to continue after discharge, he was only treated on one occasion, without follow-up, for right shoulder complaints. He indicated that such would typically be found in someone with an acute injury that did not result in chronic problems. However, at the April 2018 Board hearing, the Veteran testified that he experienced a continuity of right shoulder symptomatology following his initial in-service injury, to include pain, limitation of range of motion, and locking, that he self-treated. Additionally, lay statements from the Veteran’s former and current spouses corroborate his reports of experiencing right shoulder symptoms during and since service that he self-treated. The Veteran also testified that he originally sought treatment for his right shoulder symptoms in 1981 at General Hospital in Indianapolis; however, he believes such records are unavailable or destroyed. Furthermore, in May 2018, the Veteran’s treatment provider, Dr. B.H., indicated that was currently treating him for right shoulder AC arthritis and impingement syndrome. He also noted that the Veteran report that, while on the monkey bars in boot camp, he felt his shoulders ‘pop.’ Dr. B.H. opined that it was possible that the Veteran sustained a right AC separation/sprain at that time that was the cause of his present condition. However, as noted previously, a September 1979 X-ray revealed no AC separation of the shoulders. Furthermore, as Dr. B.H. couched his opinion in speculative terms, indicating only a possible relationship, the Board cannot rely upon it to grant service connection. Nonetheless, in light of the Veteran’s, as well as his former and current spouses’, statements, regarding a continuity of right shoulder symptomatology during and since service, and Dr. B.H.’s indication of a possible relationship between the Veteran’s in-service injury and his current right shoulder disorder, the Board finds that a remand is necessary in order to obtain an addendum opinion that considers such evidence. The matter is REMANDED for the following action: 1. Return the record the examiner who conducted the February 2013 VA examination. The record must be made available to the examiner. If the February 2013 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s right shoulder disorder had its onset during, or is otherwise related to, his military service, to include his reported injury while using the monkey bars during basic training and/or his documented complaints regarding right shoulder symptoms in July 1978, which was diagnosed as supraspinous tendonitis, and September 1979. In offering such opinion, the examiner should consider the Veteran’s, as well as his former and current spouses’, statements regarding a continuity of right shoulder symptomatology following his initial in-service injury, to include pain, limitation of range of motion, and locking, that he self-treated, and his report that, while he sought treatment for right shoulder complaints in 1981, such records are unavailable. He or she should further consider Dr. B.H.’s May 2018 opinion that it was possible that the Veteran sustained a right AC separation/sprain while on the monkey bars that was the cause of his present condition. A rationale should be provided for any opinion offered. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jonathan M. Estes, Associate Counsel