Citation Nr: 18158832 Decision Date: 12/18/18 Archive Date: 12/17/18 DOCKET NO. 17-60 820 DATE: December 18, 2018 REMANDED Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to service connection for a cervical spine disorder is remanded. REASONS FOR REMAND The appellant is a Veteran who has confirmed active duty service from June 1980 to July 1980, from August 1990 to November 1990, and from January 1991 to August 1991, with additional service in the Reserves. These matters are before the Board of Veterans' Appeals (Board) on appeal from an April 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board regrets additional delay, but finds it cannot make a fully-informed decision on the issues of service connection for right shoulder and neck disabilities without additional development. Initially, it appears the Veteran had periods of active duty service that have not been confirmed. The available DD Form 214s show she had service from August 1990 to November 1990 and from January 1991 to August 1991, but note she had one year and four months of prior active service. A December 2016 VA Information report notes she also served from June 1980 to July 1980, but does not account for the other prior active duty service. On remand, the Veteran’s periods of active duty service should be confirmed. If there are outstanding service treatment records (STRs) associated with any previously unconfirmed period of service, they should be obtained. In addition, there is conflicting evidence regarding the nature of the Veteran’s current right shoulder disorder. A March 2008 private treatment record notes a CT scan showed degenerative changes in both shoulders. However, the Veteran was provided a VA shoulder examination in December 2016, and a right shoulder strain was diagnosed. The Veteran reported she had experienced right shoulder pain since service and believed it was caused by heavy lifting while deployed to Saudi Arabia. The examiner opined the right shoulder strain was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted the Veteran’s service treatment records show that she had a right shoulder strain in 1980, but that it resolved by March 1980, and there was no evidence of chronicity. The examiner also noted an X-ray showed no abnormalities and that muscle strains usually resolve on their own. Accordingly, the Board finds a remand is necessary to arrange for an examination to reconcile the conflicting medical evidence regarding the nature of the Veteran’s current right shoulder disorder and to obtain an addendum opinion regarding whether such disability is related to service. This clarification is particularly necessary because the VA examiner based her opinion on the diagnosis of a strain. The Veteran was also provided a VA cervical spine examination in December 2016. The examiner opined it was less likely than not that the cervical spine degenerative arthritis was incurred in or was caused by the claimed in-service injury, event, or illness. The examiner noted the Veteran’s STRs show she complained of a stiff, sore neck in November 1990, but was not seen for a neck condition again on active service. The examiner noted the Veteran did not complain of neck pain again until the early 2000s. However, in an August 2016 letter, a private chiropractor noted the Veteran had been treated for recurring neck and right shoulder pain since July 1983. In her November 2017 substantive appeal, the Veteran reported she sought non-military treatment for her claimed disabilities because she was told to keep quiet about her medical issues. The chiropractor opined the Veteran’s cervical spine disorder was related to her military service and the physical activity it entailed as a flight medical technician. However, no rationale was provided for this opinion. Accordingly, the Board finds a remand is also necessary to arrange for an addendum opinion to reconcile the conflicting evidence regarding the onset of the Veteran’s current cervical spine disorder. Finally, in her November 2017 substantive appeal, the Veteran asserted that she had sought private treatment for the claimed cervical spine and right shoulder disorders during and since service and implied she was attempting to obtain these records. As noted, a private chiropractor noted the Veteran had been treated for recurring neck and right shoulder pain since July 1983, but the complete records of such treatment have not been received. On remand, the Veteran should be asked to furnish, or to furnish an authorization to enable VA to obtain, any additional private treatment records from providers who treated her claimed disabilities. The matters are REMANDED for the following action: 1. Contact the appropriate agency to confirm all of the Veteran’s periods of active duty service. All efforts to confirm the active duty periods should be clearly documented in the claim file. Any STRs associated with a previously unconfirmed period of active duty service should be sought and associated with the claims file. 2. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford her an opportunity to submit any copies in her possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. After obtaining any outstanding records, return the claims file, to include a copy of this remand, to the December 2016 examiner for an addendum opinion. If the examiner who drafted the December 2016 report is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner is asked to furnish opinions with respect to the following: (a) Identify each currently diagnosed right shoulder disorder. The examiner should specifically address the March 2008 notation of degenerative changes in both shoulders and the December 2016 VA examiner’s diagnosis of a shoulder strain. (b) Is it at least as likely as not (a 50% or better probability) that the right shoulder disorder is related to an in-service injury, event, or disease, including heavy lifting in service. The examiner should specifically address the Veteran’s contention that her right shoulder pain manifested in service when she lifted heavy sandbags while deployed to Saudi Arabia and that her shoulder pain has continued since. (c) Is it at least as likely as not (a 50% or better probability) that the cervical spine disorder is related to an in-service injury, event, or disease, including the neck problems noted in November 1990? The examiner should specifically address the chiropractor’s August 2016 opinion and the Veteran’s contention that her current neck pain manifested in service when she lifted heavy sandbags and soldiers on stretchers while deployed to Saudi Arabia and that her neck pain has continued since. A complete rationale should be provided for each opinion. KRISTY L. ZADORA Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD William Skowronski, Associate Counsel