Citation Nr: 19182000 Decision Date: 10/29/19 Archive Date: 10/29/19 DOCKET NO. 15-09 812 DATE: October 29, 2019 REMANDED Entitlement to service connection for a left shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from April 1970 to December 1971. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a January 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In June 2018, the Board remanded the Veteran’s appeal to the RO for further evidentiary development. Entitlement to service connection for a left shoulder disability is remanded. The Board remanded this matter for additional development in June 2018, directing the RO to obtain updated VA treatment records and obtain an addendum opinion (examination optional) to address direct service connection, and to address specifically (1) the November 17, 1970, Individual Sick Slip stating “injury to shoulder” and “no lifting (heavy) w L arm x 1 week,” (2) the April 20, 1971, request for an examination of the Veteran’s left and right shoulders, noting “it is the left AC joint which is somewhat wider,” and (3) the April 2011 written statement from the Veteran, and (4) the April 2011 written lay evidence from the Veteran’s spouse, relatives, and friends regarding their observations of the Veteran’s left shoulder symptoms. The RO obtained updated VA treatment records in March 2019 and an addendum medical opinion was prepared later that month. The physician concluded that the current left shoulder disability was less likely than not caused by the November 1970 injury. The opinion listed the evidence immediately above but did not address or discuss it and did not appear to consider the lay statements submitted in support of the Veteran’s claim. The physician’s rationale was based on the absence of evidence of a left shoulder condition from 1970 for the following 30 years, and the Veteran’s failure to mention left shoulder problems during treatment by VA health care in the 1990s. The physician also indicated that the findings on a May 2012 MRI did not support a nexus to the documented 1970 injury but did not clearly provide a rationale for this conclusion. The Board is required to ensure compliance with its remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Therefore, remand is required to obtain an opinion that substantially complies with the above prior remand directives. The matter is REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from March 2019 to the present. 2. Forward the claims file to the examiner who completed the March 2019 opinion to provide an addendum opinion regarding the etiology of the Veteran’s left shoulder disability, to include the injury to the left shoulder in November 1970. The examiner is asked to clarify the rationale for his opinion by providing further explanation for the statement that the May 2012 MRI results do not support a nexus with the documented injury in 1970, and to clearly discuss the significance, if any, of the evidence cited in (a) through (d) below. If the March 2019 examiner is not available, then forward the claims file to another examiner to obtain the requested opinion. If the examiner determines that the requested opinion cannot be provided without an examination, the Veteran should be scheduled for an examination. After reviewing the relevant evidence, the examiner must opine: Is it at least as likely as not (50 percent or greater probability) that the Veteran’s current left shoulder disability had its onset during or was causally related to his military service, to include an injury to one or both shoulders in November 1970? In determining whether the Veteran’s left shoulder disability is related to his military service, the clinician should review the claims file and specifically address the following: (a.) The November 17, 1970, Individual Sick Slip stating “injury to shoulder” and “no lifting (heavy) w L arm x 1 week;” (b.) The April 20, 1971, request for an examination of the Veteran’s left and right shoulders noting “it is the left AC-joint which is somewhat wider;” (c.) The April 2011 written statements from the Veteran describing the 1970 injury and his subsequent pain and functional limitations; and (d.) The April 2011 written statements from the Veteran’s friends and family regarding their observations of the Veteran’s symptoms of a left shoulder disability. The examiner must provide a detailed rationale for any opinion expressed. If an opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training) M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Dean, 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.