Citation Nr: 18160001 Decision Date: 12/20/18 Archive Date: 12/20/18 DOCKET NO. 16-48 629 DATE: December 20, 2018 REMANDED Entitlement to service connection for right shoulder injury with rotator cuff surgery is remanded. Entitlement to service connection for a right knee condition is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for scar, right shoulder status post-surgical procedure (claimed as scar, right rotator cuff) is remanded. REASONS FOR REMAND A May 2011 RO Rating Decision indicates that the Veteran served on active duty for 20 years from July 1980 to July 2000. However, the only DD Form 214 associated with the claims file, which will be discussed further below in the remand section, shows service dates from October 1987 to July 2000. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a May 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).   1. Entitlement to service connection for right shoulder injury with rotator cuff surgery. 2. Entitlement to service connection for right knee condition. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for scar, right shoulder status post-surgical procedure (claimed as scar, right rotator cuff). The claims file contains an October 2001 email from the Agency of Original Jurisdiction (AOJ) stating that only a portion of the Veteran’s service treatment records (STRs) were associated with the claims file. A response email in the same month states the STRs were transferred to the AOJ’s office in June 2001. A records request confirmation email shows that the claims file was transferred to the AOJ in approximately June 2001. There is no further documented communication between the AOJ and any other repository in pursuit of the missing records. However, during a phone call in November 2001, the Veteran stated that his initial enlistment records were lost. Moreover, he asserted that there were copies of the initial records at the Pentagon from what he had been told. A review of the entire claims files reveals that there are indeed missing records. The medical records begin in October 1984 after his fist re-enlistment in July 1980. There is an October 1984 re-enlistment examination, however his initial enlistment examination as well as any medical records prior to October 1984 are not associated with the claims file. Furthermore, there are no personnel records associated with the file other than a DD Form 214 with the dates of service from October 1987 to July 2000. There is no DD Form 214 for his first 7 years of service, in addition to the fact that there are no other pertinent training records, unit of assignment records or other probative information that could impact the claim. Therefore, remand of all issues on appeal is warranted in order to associate or determine if the missing records cannot be located. Furthermore, the Veteran should be rescheduled for additional hearing loss and right knee VA etiology examinations. The April 2015 hearing loss examination report stated a review of the claims file and service medical records revealed the Veteran to have normal hearing sensitivity at both the entrance and separation exams with no significant threshold shifts. The examiner relied on this, along with normal hearing at separation, to provide a negative nexus opinion. The Board that this examination is based on an inaccurate factual premise because there is currently no initial entrance examination associated with the claims file. Therefore, there is no definitive way to determine if a significant threshold audio shift occurred related to his hearing during his active service. Regarding the May 2015 VA examination for his right knee, the examiner did not discuss a car accident documented in the STRs showing an injury to his right knee in October 1986. Although the examiner did not provide a current diagnosis for the right knee; the current symptomatology could be as a result of residual effects from the car accident therefore another examination is warranted. Additionally, updated VA treatment records should be associated with the record on remand. See Sullivan v. McDonald, 815 F.3d 786, 792 (Fed. Cir. 2016) (finding that because § 3.159(c)(3) expanded the VA’s duty to assist to include obtaining VA medical records without consideration of their relevance.) The matters are REMANDED for the following actions: 1. Update/Obtain VA treatment records from March 2018 to the present. Document all requests for information as well as responses in the claims file. 2. Request records from the appropriate repository/repositories for verification of the Veteran’s personnel and medical records, specifically all personnel records from his enlistment to discharge and medical records prior to October 1984. Document all requests for information as well as responses in the claims file. 3. After completion of step #1 and #2, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his bilateral hearing loss disability. The examiner must opine is it at least likely as not related to an in-service injury, event, or disease. A comprehensive rationale is to accompany the opinion. 4. After completion of step #1 and #2, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his right knee condition. The examiner must opine is it at least likely as not related to an in-service injury, event, or disease. A comprehensive rationale is to accompany the opinion. The examiner is to specifically discuss: Whether or not the October 1986 auto accident where the Veteran experienced knee trauma is related to his current knee symptomatology. 5. After completion of step #1 and #2, if the currently missing personnel or medical records indicate and in-service incident related to his right shoulder; then schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his right shoulder condition. The examiner must opine is it at least likely as not related to an in-service injury, event, or disease. A comprehensive rationale is to accompany the opinion. 6. After completion of step #1 and #2, if the currently missing personnel or medical records indicate an in-service incident related to his right shoulder; then schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his right shoulder scar. The examiner must opine is it at least likely as not related to an in-service injury, event, or disease. A comprehensive rationale is to accompany the opinion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for so doing. Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. M. Williams, Associate Counsel