Citation Nr: 20021338 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 09-07 829 DATE: March 25, 2020 REMANDED Entitlement to service connection for a bilateral shoulder disorder, to include as secondary to a service-connected lumbar spine disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1989 to February 1990. This matter is on appeal from a November 2009 decision of a Department of Veterans Affairs (VA) Regional Office (RO). The case was previously before the Board in April 2015 when it was remanded for further development. Entitlement to service connection for a bilateral shoulder disorder, to include as secondary to a service-connected lumbar spine disability, is remanded. The Veteran contends that she is entitled to service connection for a bilateral shoulder disorder, to include as secondary to a service-connected lumbar spine disability.   As discussed above, this matter was remanded for further development in April 2015, and the Veteran was provided with a VA examination in February 2016. The April 2015 remand instructed the examiner to provide an opinion addressing whether the Veteran’s shoulder disorder is caused or aggravated by the Veteran’s service-connected lumbar spine disability. However, the examiner did not provide an opinion addressing secondary aggravation, as instructed in the remand. As such, an additional opinion must be obtained to determine whether secondary service connection is warranted and ensure substantial compliance with prior remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Additionally, the Board finds that clarification is necessary to determine whether a current disability exists in each shoulder. During the February 2016 examination, the examiner noted bilateral trapezial myofascitis as the claimed condition but stated that there was no shoulder joint pain or pathology. When describing the claimed condition, the examiner stated that “the onset of her ‘shoulder’ issues began 8 years ago so [there] is a credible issue with proximity.” February 2015 VA treatment records note that the Veteran’s shoulder condition is psychogenic in nature. However, January 2020 VA MRI results submitted by the Veteran reflect that an MRI of the left shoulder revealed changes of inflammation adhesive capsulitis. As such, the Board finds that the examiner must provide an opinion which clearly addresses whether a current disability exists in each shoulder. The record also reflects the Veteran receives VA treatment; thus, updated VA treatment records should be associated with the claims file. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from January 2019 to the present. 2. After completing the development in item 1, obtain an addendum opinion from the February 2016 examiner, or another appropriate clinician if that examiner is not available. The reviewing clinician should be requested to provide an opinion (based on a review of the record) to address the following: (a.) Provide a diagnosis for the Veteran’s bilateral shoulder condition, if possible. If a diagnosis cannot not be provided, provide an opinion as to whether the bilateral shoulder condition causes functional impairment in earning capacity. In providing an opinion, the examiner is asked to consider the February 2009 whole body bone scan which notes minimal degenerative inflammatory changes involving the shoulders, the translated May 2012 statement from J.Q. which states that he has to massage her daily to help relieve her shoulder pain, and the January 2020 MRI results of the left shoulder indicating changes of inflammation adhesive capsulitis. (b.) For any shoulder disorder diagnosed in either shoulder, to include any pain or other symptoms causing functional impairment, is it at least as likely as not (a 50 percent or greater probability) that the condition is proximately caused or aggravated (i.e., any increase in the disability beyond its natural progression) by her service-connected lumbar spine disability? A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be   rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. H. White, 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.