Citation Nr: 1818149 Decision Date: 03/23/18 Archive Date: 04/03/18 DOCKET NO. 13-22 666 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUE Entitlement to service connection for residuals of right shoulder injury. REPRESENTATION Veteran represented by: Mary K. Hoefer, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. R. Watkins, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1985 to November 1992 and from October 2001 to December 2004; he also had periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) in the Iowa Army National Guard, including from January to April 1982 and in August 1983. This matter originally came to the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. In April 2014, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the proceeding is included in the claims file. In May 2015, the Board denied the claim of entitlement to service connection for residuals of a right shoulder injury. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In September 2016, the Court issued a Memorandum Decision, which vacated and remanded the Board's May 2015 denial. In September 2017, the Board remanded the appeal for development consistent with Court's decision. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND In April 2014, the Veteran testified that he injured his right shoulder when he fell on ice during his active service. Following his injury, he experienced continued right shoulder pain and was unable to hold his M-16 or do push-ups. The September 2016 Court Memorandum Decision found that the June 2013 VA examination was inadequate. The Court highlighted a May 2004 private magnetic resonance imaging (MRI), which revealed possible degenerative joint disease of the right shoulder and a December 2011 VA examination that noted positive tests that suggested possible rotator cuff symptomatology, including muscle tears. The June 2013 examiner only diagnosed right shoulder impingement and did not provide a rationale for his conclusion that this was the Veteran's only right shoulder disability. In September 2017, the Board remanded the appeal to afford the Veteran with an adequate VA examination consistent with the Court's decision. In October 2017, the Veteran was afforded a VA examination. The VA examiner found that the Veteran's right shoulder was less likely than not related to the Veteran's active service. The VA examiner found that the Veteran's treatment records were silent for any right shoulder injuries or complaints. He also indicated that a review of the electronic medical records from September 7, 1994 to December 201 (sic) do not reveal any complaints of right shoulder pain. A March 2003 individual sick slip indicates that the Veteran suffered from a right shoulder strain with slightly bruised musculature over the right humeral heard and a strained cervical strain after his February 2003 fall. Additionally, a 2004 private treatment record notes that the shoulders likely reflect joint-centered processes such as degenerative joint disease. The Board finds that the October 2017 VA medical opinion is inadequate because it does not address the Veteran's lay assertion regarding continuity of symptomatology since service. Additionally, the VA examiner inaccurately stated that the Veteran did not have any in-service complaints or treatment for the right shoulder. Based upon the forgoing, a remand is necessary to obtain an adequate VA medical opinion. Accordingly, the case is REMANDED for the following actions: 1. Refer the Veteran's VA claims file to a suitably qualified VA medical professional for a supplemental opinion as to the etiology of the Veteran's right shoulder disability. If, after a review of the claims file, the examiner determines that a VA examination is necessary, such must be scheduled and the Veteran must be notified. Upon a review of the record and examination of the Veteran, the examiner should respond to the following: a. Identify all diagnosable right shoulder disabilities. b. For each diagnosed right shoulder disability, state whether it is at least as likely as not (50 percent probability or more) that any right shoulder disability began in service, was caused by service, or is otherwise etiologically related to the Veteran's military service. In rendering the requested diagnoses and opinions, the examiner must address the Veteran's March 2003 sick slip, the May 2004 private MRI that revealed possible degenerative joint disease of the right shoulder, and a December 2011 VA examination that noted positive tests that suggested possible rotator cuff symptomatology, including muscle tears. The VA examiner must also address the Veteran's lay statements regarding a continuity of symptomatology since service. A complete rationale must be provided for any opinion offered. 2. Upon completion of the above requested development and any additional development deemed appropriate, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided with a supplemental statement of the case, and an appropriate period to respond. Then, return the appeal to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). _________________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board is appealable to the Court. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).