Citation Nr: 18155441 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 15-14 943 DATE: December 4, 2018 REMANDED Entitlement to service connection for left shoulder condition is remanded. REASONS FOR REMAND The Veteran served on active duty for training (ACDUTRA) in the U.S. Army National Guard from January 2011 to March 2011. This appeal to the Board of Veteran’s Appeals (Board) arose from a July 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office. The Veteran has perfected a timely appeal. See July 2013 Notice of Disagreement; February 2015 Statement of the Case (SOC); March 2015 Substantive Appeal (VA Form 9). The Veteran requested a hearing before the Board. The requested hearing was conducted in November 2017 by the undersigned Veterans Law Judge. A transcript of the hearing is associated with the file. 1. Entitlement to service connection for left shoulder condition is remanded. After a thorough review of the Veteran's claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of the Veteran’s claim of entitlement to service connection for a left shoulder condition. The Board should note that the Veteran was denied service connection for his left shoulder condition because there was no current diagnosis of a left shoulder disability. The Veteran has contended that he experiences pain and limited range of motion in his left shoulder. According to Saunders v. Wilkie, 886 F.3d 1356 (2018), the presence of pain alone can be considered a disability if the pain reaches the level of functional impairment of earning capacity. Turning now to the evidence of the record, in an August 2015 VA examination, the Veteran stated that he had limited range of motion in his left shoulder, and was awaiting surgery for his left shoulder. The range of motion for his left shoulder was noted as abnormal or outside of normal range. A rotator cuff condition was suspected for his left shoulder. It was noted that his shoulder condition affected his ability to perform occupational tasks, such as lifting and reaching up, out, and back. In a VA treatment record dated September 2015, it was noted that given the contour of the acromion, os acromiale in the left shoulder is not excluded. There were no significant degenerative changes of the acromion; soft tissues were normal. It was also noted in the same month that the Veteran would need to have surgery on his left shoulder. At the November 2017 hearing, the Veteran expressed that he has pain in his shoulders daily. He experiences limited range of motion, such as not being able to extend his arms out, forward, or backwards. He is unable to lift up a certain amount of weight or his children. At the hearing, it was noted that the Veteran was unable to lift his left arm using the shoulder joint for purposes of raising his right hand for the oath. Based on the evidence of the record, the Board has determined that the Veteran’s left shoulder pain reaches the level of functional impairment outlined in Saunders. Thus, the Veteran has a current disability regarding his left shoulder. The Board has also found that an in-service event or injury occurred. During the November 2017 hearing, the Veteran expressed that the symptoms were brought on by carrying his TA50 gear while in training. He stated that at the time, his right shoulder was hurting more than his left shoulder. Further, he notes that he was examined and a tear was found in his right shoulder. At that time, he claims he was given a diagnosis for both shoulders. He contended that since his right shoulder was causing him more pain, more focus was directed at examining the right shoulder than the left shoulder, but he did receive a diagnosis for the left shoulder. In a March 2011 service treatment record, there is a note regarding the Veteran having shoulder symptoms. As noted in the hearing testimony, there were more notations regarding the condition of the right shoulder than the left shoulder. The Veteran was diagnosed with shoulder impingement. Severe pain in the right shoulder was noted. The examiner concluded that the Veteran is no longer able to train and was recommended that he separates from service due to his condition. A VA treatment record dated July 2013 states that the Veteran was diagnosed with os acromiale in 2010 and began having shoulder pain symptoms in 2004. The pain flared up in 2011 when he entered basic training. However, the medical records show that the Veteran was diagnosed with os acromiale of the right shoulder in 2011. In another VA treatment record dated July 2013, the Veteran stated that he had been experiencing bilateral shoulder pain for two years. The Veteran’s account of his symptoms and his training indicate that he encountered a situation that was consistent with the places, types, and circumstances of his active service, specifically his training. See 38 U.S.C. §1154(a). Resolving reasonable doubt in favor of the Veteran, the Veteran’s lay statements regarding what actions led to his shoulder pain, taken with medical evidence, present a plausible picture of what he experienced at the time, and are sufficiently reliable and thus credible to support a finding of an in-service onset of left shoulder pain. Based on the evidence of the record that establishes a current diagnosis of a left shoulder disability, and an in-service injury and complaints regarding shoulder pain, the Board finds that a VA examination is necessary in accordance with McClendon v. Nicholson, 20 Vet. App. 79 (2006), to examine the nature and etiology of the Veteran’s left shoulder condition and determine if his left shoulder condition is related to his active service. The matter is REMANDED for the following action: 1. Provide the Veteran an opportunity to identify any pertinent treatment records for his claimed left shoulder disability. The RO/AMC should secure any necessary authorizations. 2. Additionally, all updated VA treatment records should be obtained. If any requested outstanding records cannot be obtained, the Veteran should be notified of such. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of his left shoulder condition. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The claims file should be made available to the examiner for review. After record review and examination, the VA examiner should offer his or her opinion with supporting rationale as to the following inquiries: (a) Does the Veteran have a current diagnosis of a left shoulder disability? (b) If the answer to (a) is yes, is it at least as likely as not (50 percent or greater probability) that the Veteran's left shoulder condition were incurred in, caused by, or etiologically related to the Veteran's service? The basis for each opinion is to be fully explained with a complete discussion of the pertinent lay and medical evidence of record and sound medical principles, including the use of any medical literature or studies, which may reasonably explain the medical analysis in the study of this case. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Syesa Middleton, Associate Counsel