Citation Nr: 18155549 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 16-58 632 DATE: December 4, 2018 REMANDED Entitlement to service connection for a right shoulder condition is remanded. Entitlement to service connection for lumbar spondylosis is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1994 to March 1995. These matters come to the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. 1. Entitlement to service connection for a right shoulder condition is remanded. The Veteran seeks service connection for a right shoulder condition. Specifically, the Veteran contends that his current right shoulder pain started during his active military service while he was in “A” school. VA must provide an examination when there is competent evidence of a disability (or persistent or recurrent symptoms of a disability) that may be associated with an in-service event, injury, or disease, but there is insufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). An August 2013 VA report of psychiatric examination documents that the Veteran reported that while in “A” school he was playing racquetball and injured his shoulder by running into a wall. The Veteran’s service treatment records (STRs) document that the Veteran complained of general body aches after playing racquetball. Post-service treatment records document consistent complaints of right shoulder pain. In correspondence dated in July 2015, the Veteran stated that he “{could}not work” and was “in pain”. The Board acknowledges that the Veteran has not been diagnosed with a current right shoulder condition during the period on appeal. However, in Saunders v. Wilkie the Court held that pain resulting in function impairment constitutes a disability as contemplated in 38 U.S.C. 1110, even in the absence of a presently-diagnosed condition. Saunders v. Wilkie, 2018 U.S. App. LEXIS 8467, *18-28 (Fed. Cir. Apr. 3, 2018). Given the Veteran’s consistent report of right shoulder pain, and the July 2015 correspondence which suggests that such pain may result in functional impairment of earning capacity, the Board finds that an examination should be provided on remand. 2. Entitlement to service connection for lumbar spondylosis is remanded. The Veteran seeks service connection for lumbar spondylosis. Specifically, the Veteran contends that his current back pain started during his active military service while he was in “A” school. VA must provide an examination when there is competent evidence of a disability (or persistent or recurrent symptoms of a disability) that may be associated with an in-service event, injury, or disease, but there is insufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon, 20 Vet. App. at 81. An August 2013 VA Psych examination report documents that the Veteran reported that while in “A” school he was playing racquetball and injured his back by running into a wall. The Veteran's STRs document that the Veteran complained of back pain during service after playing racquetball and that he was diagnosed with back muscle strain. Post-service VA treatment records confirm a diagnosis of spondylolisthesis of the lumbar region. See April 2013 Metro Health Hospital Records. The Board finds that the threshold of the McLendon standard has been met, and that the Veteran should be afforded an initial VA examination. See Id. The matters are REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of his relevant treatment that have not yet been associated with the claims file, and associate with the claims file any outstanding VA treatment records. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right shoulder disability. The claims file should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disabilities, including the Veteran's competent account of his symptoms. Following review of the claims file and examination of the Veteran, the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or more) that the Veteran has a right shoulder disability that had its onset in service, or within one year of his separation from service, or is otherwise related to service. In rendering this opinion, the examiner is asked to specifically address the Veteran's contention that he injured his right shoulder while playing racquetball/when he ran into a wall. The examiner is also asked to address the complaint of body aches documented in the Veteran’s STRs. (b.) In the event that the criteria for a diagnosis of a right shoulder condition are not met, the examiner should specifically state whether there is any functional impairment associated with the Veteran’s complaints of right shoulder pain. If there is functional impairment, the examiner should opine as to whether it is at least as likely as not that such impairment is associated with the Veteran’s service, to include the injury sustained while playing racquetball. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his lumbar spondylosis. The claims file should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disabilities, including the Veteran's competent account of his symptoms. Following review of the claims file and examination of the Veteran, the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or more) that the Veteran has back disability, including lumbar spondylosis, that had its onset in service, or within one year of his separation from service, or is otherwise related to service. In rendering this opinion, the examiner is asked to specifically address the Veteran's contention that he injured his back while playing racquetball/when he ran into a wall. The examiner is also asked to address the complaint of back pain and diagnoses of back muscle strain documented in his STRs. S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Smith-Jennings, Associate Counsel