Citation Nr: 19178652 Decision Date: 10/15/19 Archive Date: 10/15/19 DOCKET NO. 10-44 436 0000DATE: October 15, 2019 REMANDED Entitlement to service connection for a left shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2001 to January 2005. This matter comes to the Board of Veterans’ Appeals (Board) from a May 2009 rating decision which, in pertinent part, denied entitlement to service connection for left shoulder pain. In July 2017, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board videoconference hearing. A copy of the transcript is of record. In December 2017, the Board remanded the claim for further development, including obtaining a new VA examination and medical opinion. Entitlement to service connection for a left shoulder disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a left shoulder disability. The Veteran contends that he injured his left shoulder during an in-service motor-vehicle accident and that he has continued to experience pain in the back of his shoulder around the scapula area and aggravation of the injury since service. The Veteran claims he did not seek treatment for the injury during service, but rather self-medicated with Motrin for the pain, as he did not want to delay his return from deployment. Service treatment records reflect that in April 2004, the Veteran was involved in a Humvee accident. The Veteran reported tenderness to palpation of the left paraspinal area at T4-T6, as well as on the right paraspinal area at T5-7. A drawing associated with the Veteran’s treatment indicates two areas of paraspinal pain, with one area near the scapula. The Veteran was afforded a VA examination in July 2010. However, in December 2017, the Board found the July 2010 examiner’s opinion inadequate as it was unclear whether the examiner considered the Veteran’s statements that his shoulder pain centers in the back of his shoulder around his scapula, service treatment records reflecting that the Veteran had left paraspinal pain at T4-T6, or the Veteran’s reasoning for not seeking medical treatment for his pain. Thus, the Board remanded the claim for a new VA examination and medical opinion. The Veteran was afforded a VA examination in June 2018. While the examiner opined that the Veteran’s left shoulder disability was less likely than not incurred in or caused by service, as the examiner did not believe that the anterior left shoulder pain is related to the reported T4-T6 left paraspinal pain, the examiner noted the Veteran suffered a concussion during the MVA and it was possible that the force of that accident resulted in a left shoulder injury. The Board finds the June 2018 VA examiner’s opinion is internally inconsistent. While the examiner opined that the Veteran’s anterior left shoulder pain was not incurred in or otherwise related to service, the examiner then indicated that as the Veteran suffered a concussion, it was possible that the force of the accident resulted in a left shoulder injury. Therefore, the Board finds that a remand is warranted for a new VA examination and medical opinion as to the nature and etiology of the Veteran’s left shoulder disability. Finally, the Veteran submitted a July 2018 and September 2018 MRI and surgical report pertaining to his left shoulder. As the Veteran appears to receive private treatment for his left shoulder, upon remand, VA should obtain authorization and request these records. The matter is REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from May 2015 to present. 2. Ask the Veteran to complete a VA Form 21-4142 for private treatment received for his left shoulder. Make two requests for the authorized records from any identified provider, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any left shoulder disability, including left shoulder subacromial impingement, biceps tendinitis, and bursitis. The examiner must opine whether the Veteran’s left shoulder disability, to include, but not limited to, left shoulder subacromial impingement, biceps tendinitis, and bursitis, at least as likely as not (1) began during active service, to include related to an in-service injury, event, or disease, including a 2004 Humvee accident and subsequent paraspinal pain at T4-T6, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service, including the Veteran’s reports that his left shoulder pain began during service, but that he self-treated with Motrin. 4. After completing the above, and any other development as may be indicated, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Owen, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.