Citation Nr: 20021891 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 17-52 494 DATE: March 27, 2020 REMANDED The issue of service connection for a left shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1965 to December 1967 and April 1970 to October 1986. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Veteran testified before the Board at a videoconference hearing. Service treatment records are silent as to complaints or treatment of a left shoulder injury or disease; however, during the January 2020 Board hearing, the Veteran testified to injuring his left shoulder while driving a mechanized vehicle in service while in the National Guard. Post-service VA treatment records reflect numerous reports of left shoulder pain for which the Veteran denied injury at the time. See, e.g., June 2010 VA treatment record. A June 2010 x-ray of the left shoulder shows joint spaces were maintained, no bony findings were noted, and humeral head contour was unremarkable. The Board has considered the Veteran’s contention that he presents with a disability manifested by left shoulder pain. To the extent that the Veteran reports left shoulder pain, pain without an identified underlying diagnosis can constitute a disability if the pain results in functional impairment. See Saunders v. Wilkie, 886 F. 3d 1356 (2018). To establish a disability based on pain, there must be evidence that the Veteran’s pain reaches the level of a functional impairment of earning capacity. Saunders, 886 F. 3d 1356 at 1367, 1368. In assessing functional impairment, the Board must consider both lay statements and objective medical evidence. 38 C.F.R. § 3.303(a). The VA has not provided the Veteran with a VA examination for the purposes of determining the nature and etiology of his alleged left shoulder disability. In light of the record, a remand for a VA examination is warranted, even if there is no current left shoulder diagnosis, in order to determine whether the Veteran’s pain rises to the level of functional impairment in line with Saunders, and to obtain a medical opinion. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. Obtain any outstanding Army National Guard service personnel and treatment records and associate them with the claims file. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of any left shoulder disability. The claims file must be made available to and reviewed by the examiner in conjunction with the opinion. First, the examiner should determine whether the Veteran has any current left shoulder disability, which may include pain alone that rises to the level of functional impairment. Then, the examiner must opine whether it is at least as likely as not (50 percent or greater probability) that any left shoulder disability had its onset during active service or is related to any in-service disease or injury, to include his report of injuring his left shoulder while driving a mechanized vehicle while in the National Guard. In providing the requested opinion, the examiner should specifically consider and discuss all pertinent medical evidence and lay assertions and the service treatment records, to include the Veteran’s January 2020 Board hearing testimony. All finding results, along with a medical rationale for the conclusions reached, must be provided. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Griffith 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.