Citation Nr: 19167232 Decision Date: 08/29/19 Archive Date: 08/29/19 DOCKET NO. 16-19 700 DATE: August 29, 2019 ORDER Entitlement to service connection for a left shoulder disorder is granted. FINDING OF FACT A left shoulder disorder, diagnosed as left shoulder impingement syndrome and rotator cuff tear, is attributable to service. CONCLUSION OF LAW The criteria for service connection for left shoulder impingement syndrome and rotator cuff tear have been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from June 1989 to June 1995. These matters come before the Board of Veterans’ Appeals (Board or BVA) on appeal from an October 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). In this decision, the Board is granting the claim being decided herein. Further discussion of the VCAA is therefore unnecessary. Wensch v. Principi, 15 Vet. App. 362, 367-368 (2001). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a) (2018). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service—the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. For chronic diseases, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Entitlement to service connection for a left shoulder disorder At the outset, the Board notes that the Veteran does not claim, and the evidence does not reflect, that his left shoulder disability is the result of combat with the enemy. Therefore, the combat provisions of 38 U.S.C. § § 1154 are not applicable. Nevertheless, the Veteran contends that his currently diagnosed left shoulder impingement syndrome with rotator cuff tear is due to his active service. The Board finds that the evidence of record demonstrates service connection for left shoulder impingement syndrome with rotator cuff tear is warranted. According to the Veteran’s service treatment records, the Veteran sought treatment for left shoulder pain beginning in August 1993; diagnoses of left shoulder rotator cuff strain and left shoulder tendonitis were noted in his service treatment records and on his “master problems” list. Post-service treatment records from Kelsey-Seybold Clinic, dated August 2009 through October 2014, indicate that the Veteran first sought treatment for his left shoulder in August 2009. The records also reflect that the Veteran consistently reported to his treating providers at the Kelsey-Seybold Clinic that his left shoulder pain began during his military service and continued to worsen in the years since service. The Veteran is competent to report continuity of symptoms. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2008) (lay evidence may suffice to prove service connection on its own merits). The initial x-ray in August 2009 showed a possible Type-II acromion. Subsequent treatment records reveal diagnoses of left shoulder impingement syndrome and rotator cuff tear. A review of December 2011 VA treatment records indicates that the Veteran complained of left shoulder pain and hearing a “pop” sound with regard to his left shoulder; he did not report a specific injury. In testifying before the undersigned VLJ in February 2019, the Veteran related that his left shoulder disorder was aggravated at that time. The Board acknowledges that the July 2013 VA examiner found that it was less likely than not that the Veteran’s left shoulder impingement syndrome with rotator cuff tear is related to his service. However, the VA examiner’s opinion lacks probative value. In this regard, the Board observes that the July 2013 VA examiner indicated that the opinion was based solely on the Veteran’s post-service VA treatment records. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (stating that factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion). To this point, the Board notes that the VA examiner found that the Veteran’s left shoulder impingement syndrome with rotator cuff tear was due to a December 2011 injury, and unrelated to his service. Likewise, the VA examiner did not address the Veteran’s continued complaints and treatment for his left shoulder impingement syndrome with rotator cuff tear in the years since service. In light of the evidence of record, the Board finds the Veteran’s report of treatment in the years since service credible. More significantly, the VA examiner did not review the Veteran’s entire claims file. The VA examiner specifically indicated that he did not review the Veteran’s service treatment records. There was also no indication that the VA examiner reviewed the treatment records from Kelsey-Seybold Clinic. Additionally, the Board observes that the VA examiner relied upon the December 2011 VA treatment records to find that Veteran’s left shoulder impingement syndrome and rotator cuff tear were incurred after service, which ignored the fact that the Veteran’s claim for service connection was filed in November 2011, prior to the alleged December 2011 left shoulder injury. Thus, the VA examiner’s reliance on this aggravation of the Veteran’s left shoulder defies logic, as the Veteran would not have filed a claim in anticipation of a future injury. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). Thus, the VA examiner’s opinion has no probative value. Thus, it is reasonable to find that the Veteran’s left shoulder impingement syndrome with rotator cuff tear is causally related to the Veteran’s in-service treatment for a left shoulder rotator cuff strain and left shoulder tendonitis. See Madden v. Gober, 125 F.3d 1477, 1481 (1997) (in evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility and probative value of proffered evidence in the context of the record as a whole). For the foregoing reasons, the most probative, and thus a preponderance of the evidence supports a finding that the Veteran’s left shoulder impingement syndrome with rotator cuff tear is related to his service. Accordingly, entitlement to service connection for left shoulder impingement syndrome with rotator cuff tear is warranted. 38 U.S.C. § § 5107; 38 C.F.R. § 3.102. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Hallie E. Brokowsky, 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.