Citation Nr: 18156657 Decision Date: 12/11/18 Archive Date: 12/10/18 DOCKET NO. 16-48 689 DATE: December 11, 2018 REMANDED Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a right shoulder disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1990 to May 1990 and from February 1991 to August 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision by the San Diego, California, Regional Office (RO) of the Department of Veterans Affairs (VA). 1. Entitlement to service connection for a left shoulder disorder is remanded. 2. Entitlement to service connection for a right shoulder disorder is remanded. Unfortunately, a remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran’s claims so that she is afforded every possible consideration. VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C. §§ 5107(a), 5103A (2012); 38 C.F.R. § 3.159(c) (2018). The Veteran claims she is entitled to service connection for left and right shoulder disorders as they stemmed from her military service. In-service treatment records reveal the Veteran complained of, and was treated for, pain in her bilateral upper extremities. In January 1990, she had pain and was unable to raise her arms over her head for two weeks and she reported neck and right shoulder pain, but denied injury. In January 1990 and February 1990, she was treated for left upper trapezius pain. However, the October 1989 Report of Medical Examination and Report of Medical History at entrance into service, and the July 1991 Report of Medical Examination and Report of Medical History at separation was absent of any symptomatology or disability of the left and right shoulders. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2018). VA’s duty to assist includes providing a medical examination when necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The RO did not provide the Veteran with an examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, the record does not indicate the Veteran has a current diagnosis of right and left shoulder disorders. However, given the evidence of the Veteran’s prior history of symptoms of pain in the bilateral upper extremities/shoulders during her military service, her history of cortisone shots over the years and as she has not been afforded a VA examination based on her symptomatology, the Board finds this additional development is warranted prior to adjudication. The matters are REMANDED for the following action: 1. Obtain copies of updated treatment records and add them to the claims file. 2. Once all outstanding records, if any, have been associated with the claims file, schedule the Veteran for examination with an appropriate examiner to determine the nature and etiology of her left and right shoulder disorders. Based on a review of the claims file, the results of the examination, and the Veteran’s statements regarding the development and treatment of her claimed bilateral shoulder disorders during and after service, the examiner is asked to clarify whether the Veteran has any shoulder disorder or manifests shoulder pain resulting in functional impairment. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that any shoulder disorder had its onset in service or is otherwise linked to service. The claims file should be provided to the examiner for review in conjunction with the examination and such should be acknowledged. All appropriate testing should be accomplished. The Veteran’s lay statements, especially regarding her symptomatology contained within the claims file and made at the examination, must be considered. The VA examiner is also asked to consider and address all relevant service treatment records. All findings and conclusions should be set forth in a legible report. A clear rationale for all opinions rendered must be made. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. BARBARA B. COPELAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Yoo, Counsel