Citation Nr: 18159048 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 17-07 597 DATE: December 18, 2018 ORDER Entitlement to service connection for traumatic joint disease of the cervical spine is granted. REMANDED Entitlement to service connection for left shoulder disability is remanded. FINDING OF FACT The Veteran’s traumatic joint disease of the cervical spine is attributable to an injury from a fall during inactive duty for training and related to the service connected residuals of neck injury. CONCLUSION OF LAW Traumatic joint disease of the cervical spine was incurred in service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303(a) (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty for training (ACDUTRA) from January 2005 to June 2005. The Veteran subsequently served periods of inactive duty for training (INACDUTRA), including on or about May 12, 2009. 1. Entitlement to service connection for traumatic joint disease of the cervical spine The Veteran contends her current cervical spine disability is due to an incident in service in which she fell approximately 15 to 18 feet and injured her back and shoulders. See August 2015 VA examinations. Here, we note that there is confusion in the record. In a statement of the case, it was reported that service connection had been denied. However, a rating decision notes that residuals of neck injury is service connected (code 1.). Furthermore, the aware document reflects payment at the 40 percent rate for the combined disabilities. We conclude that the rating decision has been promulgated. Service connection has been granted for residuals of a neck injury. The Board concludes that the Veteran has joint disease of the cervical spine that was incurred during INACDUTRA in May 2009. An August 2015 VA cervical spine examination shows the Veteran has joint disease of the cervical spine supported by imaging. The VA examiner opined that the Veteran’s disability was at least as likely as not incurred in or caused by the May 2009 fall. A review of the evidence of record reveals a line of duty determination which documented the Veteran fell and hurt multiple body parts, including her back and right shoulder, during INACDUTRA in May 2009. This determination report also contained a medical opinion that it is at least as likely as not that the Veteran’s injuries would result in a claim against the government for future medical care. Service treatment records also reveal treatment for her back and right shoulder at the time of the fall and after. In light of the AOJ grant of service connection for residuals of neck injury, promulgation of an award and the VA opinion, the residuals of neck trauma include traumatic changes. REASONS FOR REMAND 1. Entitlement to service connection for left shoulder disability is remanded. Upon review of the evidence of record, the Board finds a remand is warranted for additional examination. The Veteran was afforded a VA shoulder examination in August 2015. The Veteran reported she has had bilateral shoulder pain since the May 2009 fall discussed above. The examiner opined the Veteran’s claimed condition was less likely than not incurred in or caused by the May 2009 fall. In support of this opinion, the examiner stated, “There are no objective findings of a bilateral shoulder condition.” Per this rationale, and in violation of Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007), the examiner did not give adequate consideration to the Veteran’s lay statements, including her reports of prior medical treatment and shoulder pain since the May 2009 fall. The examiner noted abnormal range of motion, but said this was normal for the Veteran due to body habitus rather than a shoulder disability. Additionally, as the examiner noted, no imaging has been taken of the Veteran’s left shoulder. The Board considers imaging to be pertinent objective evidence, particularly when considering the examiner’s reliance on a lack of objective evidence to determine the Veteran does not have a left shoulder disability. In light of the issues above, remand is warranted for additional examination. The matter is REMANDED for the following action: 1. Obtain outstanding VA records of evaluation and treatment. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any left shoulder disability. The examiner must opine whether it is at least as likely as not related to service, including the Veteran’s May 2009 fall. The examination should include evaluation of imaging of the Veteran’s left shoulder. Such imaging should be provided to the Veteran if necessary. The examiner must provide a complete rationale for all opinions provided, including addressing the lay evidence of record, including the Veteran’s report of left shoulder pain since May 2009. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Gregory T. Shannon, Associate Counsel