Citation Nr: 20004789 Decision Date: 01/21/20 Archive Date: 01/21/20 DOCKET NO. 17-60 931 DATE: January 21, 2020 REMANDED Entitlement to service connection for a left shoulder disability is remanded. REASONS FOR REMAND The Appellant had active duty for training from July 1989 to October 1989 with additional service in the Army National Guard. In October 2019, the Appellant testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In his substantive appeal, the Appellant discussed the issue of entitlement to service connection for hearing loss. However, the record shows that the Appellant did not submit a timely notice of disagreement as to a December 2015 rating decision that denied that issue. In addition, the statement of the case in this appeal did not adjudicate the issue. Therefore, the issue is not on appeal before the Board at this time. See 38 C.F.R. §§ 20.201, 20.202; see also Percy v. Shinseki, 23 Vet. App. 37 (2009). Entitlement to service connection for a left shoulder disability is remanded. The Appellant seeks entitlement to service connection for a left shoulder disability, which he contends began during his period of active duty for training as a result of performing training exercises and carrying a ruck sack. He has submitted private treatment records dated in 2004 and 2005 that show he had an insidious onset of left shoulder pain around the beginning of May 2004 and underwent a left shoulder arthroscopy with repair of SLAP tear in January 2005. They also reference an AC joint separation the Appellant reportedly had in high school and show that he reinjured his shoulder while lifting weights in October 2005. The Appellant has also submitted a single treatment note from S. W. Shick, M.D., dated in April 2019 in which Dr. Shick states, “Certainly shoulder instability in a young infantryman is a common problem. His operative findings with Dr. Learning indicated chronic subluxation of the glenohumeral joint. It is medically likely that his time in the military with the heavy demands on his left shoulder was the inciting factor in his left shoulder subluxation. He had no problems in high school prior to enlisting in the military despite playing multiple sports.” Dr. Shick notes that he did not review any records from the Appellant’s first left shoulder surgery in 2005. He also references a second surgery on the Appellant’s left shoulder that took place in September 2008 and was performed by Dr. Learning. The private treatment records submitted by the Appellant appear incomplete. The earliest record submitted is a report for MR imaging performed on the Appellant’s left shoulder in December 2004. The submitted records do not include records pertaining to the insidious onset of the Appellant’s left shoulder pain in or around May 2004 or records leading up to the December 2004 MR imaging. In addition, they do not include records pertaining to the Appellant’s second left shoulder surgery in 2008, which Dr. Shick referenced and the Appellant discussed at the October 2019 Board hearing. The Board finds that the issue must be remanded so that the Appellant may be given an opportunity to identify and authorize release of any outstanding relevant medical treatment records. The Board further finds that Dr. Shick’s April 2019 opinion is not probative because it is vague and does not reflect consideration of the medical treatment records relating to the Appellant’s first left shoulder surgery, which describe the onset of left shoulder symptoms as insidious and do not reference the Appellant’s active duty for training or service in the National Guard. However, Dr. Shick’s opinion does indicate that the Appellant’s current left shoulder disability may constitute an injury stemming from the Appellant’s active duty for training. Therefore, the Board concludes that the threshold for providing a VA examination has been met, and that the Appellant must be provided such an examination. The matters are REMANDED for the following action: 1. Ask the Appellant to complete a VA Form 21-4142 for Any relevant private treatment records dating prior to December 2004 and after October 2005, to include records pertaining to his second left shoulder surgery. Make two requests for any authorized records unless it is clear after the first request that a second request would be futile. If any authorized records cannot be obtained, send the Appellant notice consistent with 38 C.F.R. § 3.159(e). 2. Schedule the Appellant for an examination by an appropriate clinician to determine the nature and etiology of any left shoulder disability. Based on a review of the record and on an examination of the Appellant, the clinician must opine whether it is at least as likely as not (50 percent or greater probability) that the Appellant’s left shoulder disability is related to an in-service injury, event, or disease, including performing training exercises and carrying a ruck sack. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. J. Anthony, 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.