Citation Nr: 19119720
Decision Date: 03/19/19	Archive Date: 03/19/19

DOCKET NO. 17-43 824
DATE:	March 19, 2019

REMANDED

Entitlement to service connection for right shoulder disability is remanded.

REASONS FOR REMAND

The Veteran served on active duty from March 2011 to June 2011, with additional periods of service including active duty for training and inactive duty for training.

1. Entitlement to service connection for right shoulder disability is remanded.

A May 2017 VA examiner opined that the Veteran’s right shoulder strain less likely than not is related to his in-service injury.  However, the VA examiner relied on the lack of documentation of right shoulder complaints in the treatment records following the initial injury without addressing the Veteran’s reports that he has had problems with his right shoulder since the in-service injury, particularly during excessive use and with weightbearing.  In addition, the VA examiner did not have the opportunity to address the Veteran’s later reports that his right shoulder has bothered him more as he compensates for his service-connected left shoulder disability.  See August 2017 VA Treatment Record.  Accordingly, remand is appropriate for further VA medical opinion.

When discussing the Veteran’s left shoulder, the VA examiner opined the Veteran’s “current right shoulder injury” was likely caused by service.  It appears clear from the remainder of the opinion that this “current right shoulder injury” reference was a typographical error and should have been left shoulder as it was made in the context of an explanation of the reasons the Veteran’s left shoulder was related to service.  

While this matter is on remand, outstanding private and VA treatment records should be obtained, including any VA treatment records from September 2017 to the present.

The matter is REMANDED for the following action:

1. After securing any necessary authorization, obtain any private treatment records as the Veteran may identify relevant to his claim.

2. Obtain additional VA treatment records from September 2017 to the present.  Associate with the claims file any relevant documents scanned into Vista Imaging but not associated with the Veteran’s claims file.

3. After obtaining any outstanding records, ask the appropriate examiner to review the Veteran’s file.  The necessity of an in-person examination is left to the discretion of the examiner.  

The examiner should identify any current right shoulder disability the Veteran has presented during the claim period (from November 2016 to the present).  For each disability, the examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that the disability is related to the February 2014 or April 2015 in-service shoulder injuries.

The examiner should also opine whether it is at least as likely as not (a 50 percent or greater probability) that the disability is (i) caused by or, (ii) was aggravated (i.e., permanently worsened beyond the natural progression) by his service-connected left shoulder disability.  

The examiner should consider all medical and lay evidence of record.  The Veteran reported that he has had problems with his right shoulder since the initial in-service injury, particularly during excessive use or with weightbearing.  The Veteran reported that his lack of treatment was due to the expense of receiving medical care.  The Veteran also reported that his right shoulder has bothered him more as he compensates for his service-connected left shoulder disability.  

The examiner is asked to explain the reasons behind any opinions expressed.  The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it.

 

BETHANY L. BUCK

Veterans Law Judge

Board of Veterans’ Appeals

ATTORNEY FOR THE BOARD	A. Purcell, Associate Counsel