Citation Nr: 20022429 Decision Date: 03/31/20 Archive Date: 03/31/20 DOCKET NO. 16-15 047A DATE: March 31, 2020 ORDER Entitlement to service connection for carpal tunnel syndrome of the right wrist is denied. Entitlement to service connection for carpal tunnel syndrome of the left wrist is denied. Entitlement to an initial disability rating in excess of 20 percent prior to September 9, 2019 and in excess of 40 percent thereafter for a lumbar strain with spondylosis at L5 (low back disability) is denied. REMANDED Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a neck disability, to include as secondary to a low back disability, is remanded. FINDINGS OF FACT 1. The most probative evidence of record has not shown that the Veteran’s carpal tunnel syndrome of his right wrist is related to his service. 2. The most probative evidence of record has not shown that the Veteran’s carpal tunnel syndrome of his left wrist is related to his service. 3. The most probative evidence of record does not show that prior to September 9, 2019, the Veteran’s low back disability presented itself with forward flexion of the thoracolumbar spine limited to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine; nor demonstrated that the Veteran’s flareups were of such frequency, severity, and duration as to entitle the Veteran to a higher disability rating. 4. For the period following September 9, 2019, the Veteran’s low back disability has not been shown to have resulted in unfavorable ankylosis of the entire thoracolumbar spine. CONCLUSIONS OF LAW 1. The criteria for service connection for carpal tunnel syndrome of the right wrist are not met. 38 U.S.C. § 1110, 5107; 38 C.F.R. § 3.303, 3.307, 3.309. 2. The criteria for service connection for carpal tunnel syndrome of the left wrist are not met. 38 U.S.C. § 1110, 5107; 38 C.F.R. § 3.303, 3.307, 3.309. 3. Prior to September 9, 2019, the criteria for entitlement to a disability rating in excess of 20 percent for a back disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.71a, Diagnostic Codes 5242, 5237. 4. For the period following September 9, 2019, the criteria for entitlement to a disability rating in excess of 40 percent for a back disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.71a, Diagnostic Codes 5242, 5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2004 to July 2004. This matter comes before the Board of Veteran’s Appeals (Board) from a January 2015 and a June 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office. These matters were previously before the Board in May 2019 when the claims were remanded for development. The Board finds the May 2019 remand directives regarding the claims for service connection for carpal tunnel syndrome and the claim for increased rating of the low back disability have been substantially complied with, and the matters are again before the Board. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board finds that the remand instructions regarding the bilateral shoulder disabilities and the neck disability have not been substantially complied with. Accordingly, the Board will address these issues in the REMAND portion of this decision. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110, §1131; 38 C.F.R. § 3.303. 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154 (a); 38 C.F.R. § 3.303 (a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Entitlement to service connection for carpal tunnel syndrome of the right wrist The Veteran asserts that his current carpal tunnel disability in his right wrist is related to his service. In specific the Veteran points to an in-service incurrence consisting of being thrown to the ground by a drill instructor. The Veteran was administered a VA Peripheral Nerves Conditions Disability Benefits Questionnaire (Nerves DBQ) in September 2019. The Veteran’s diagnosis of bilateral carpal tunnel syndrome was noted. The Veteran explained he suffers from cramping of his hand muscles sporadically and complained of numbness on his middle fingers of both hands and his lateral palmar hands. The Veteran also described having used his hands to land when thrown to the ground by a drill instructor during service. See Nerves DBQ of September 2019. In a September 2019 VA medical opinion the examiner opined that although the Veteran’s STRs show his right wrist was immobilized following his in-service incident, that the symptoms at the time of the injury did not appear to have involved the median nerve as is in the case with carpal tunnel syndrome. Additionally, the examiner noted that carpal tunnel syndrome is often a condition associated with cumulative trauma such as repetitive wrist flexion and extension or using the hands and wrists for forceful activities over time and at times with a fracture or space occupying lesion close to the median nerve. The examiner pointed out that no fracture or space occupying lesion was identified in the Veteran during his military service and that a single event did not qualify for repetitive trauma. The examiner further noted the Veteran could not recall how long his symptoms of numbness and cramping of his hands had been present. Accordingly, the examiner opined the Veteran’s carpal tunnel syndrome of the right hand was less likely than not incurred in or cause by the claimed in-service injury, event or illness. The Board finds this medical opinion adequate, as it provides a complete rationale for the opinion expressed and assigns it high probative value. Based on the above discussion the Board finds that the Veteran’s claim surpasses the first and second prongs of the Shedden service connection test; a current disability and an in-service incurrence. However, the Board notes that as there is a negative opinion regarding the Veteran’s condition and its relation to service; the claim does not surpass the third prong of the Shedden service-connection test; the nexus requirement. The Board notes that although the Veteran is competent to report his symptoms of pain and numbness in his hands and wrists; he is not competent to provide a medical opinion as to the etiology of his carpal tunnel syndrome. Layno v. Brown, 6 Vet. App. 465, 469 (1994). As the Veteran’s claim does not surpass the third prong of the Shedden service-connection test, the Board finds the preponderance of the evidence is against finding the Veteran’s carpal tunnel syndrome of his right wrist is related to service and the claim must be denied. 2. Entitlement to service connection for carpal tunnel syndrome of the left wrist The Veteran asserts that his carpal tunnel syndrome in his left wrist is related to service. In the September 2019 Nerves DBQ, the Veteran was diagnosed with carpal tunnel syndrome in his left hand. In this examination the Veteran described his in-service incurrence of being thrown to the ground by a drill instructor. Accordingly, the Board finds the Veteran’s claim surpasses the first and second prongs of the Shedden service-connection test; a current disability and an in-service incurrence. Now, the question that remains before the Board is whether the Veteran’s current carpal tunnel syndrome of his left wrist is related to his in-service incurrence; the nexus requirement. In a September 2019 VA medical opinion, the examiner opined that although the Veteran did suffer a wrist injury during service; that the injury was to his right hand and not to his left hand. The examiner further explained that carpal tunnel syndrome is often a condition associated with cumulative trauma such as repetitive wrist flexion and extension or using the hands and wrists for forceful activities over time and at times with a fracture or space occupying lesion close to the median nerve. Accordingly, the examiner opined that the Veteran’s carpal tunnel syndrome was less likely than not related to his service. The Board finds this medical opinion adequate and assigns it high probative value. Accordingly, the Board finds that the claim does not surpass the third prong of the Shedden service-connection test; the nexus requirement. The Board notes that although the Veteran is competent to report his symptoms of pain and numbness in his hands and wrists; he is not competent to provide a medical opinion as to the etiology of his carpal tunnel syndrome. Layno v. Brown, 6 Vet. App. 465, 469 (1994). As the Veteran’s claim does not surpass the third prong of the Shedden service connection test, the Board finds that the preponderance of the evidence is against finding the Veteran’s current carpal tunnel syndrome of the left wrist is related to service, and service connection for a left wrist disability must be denied. 3. Entitlement to an initial disability rating in excess of 20 percent prior to September 9, 2019 and in excess of 40 percent thereafter for a lower back disability The Veteran contends that his disability rating of 20 percent prior to September 9, 2019 and of 40 percent thereafter do not reflect the severity of his back disability. The Board notes the Veteran disagreed with the initial disability rating granted. Accordingly, the appeal period for this claim is from July 9, 2014, the effective date of the award of service connection for the Veteran’s back disability. Disability evaluations are determined by the application of the Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practicably be determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. While a veteran’s entire history is reviewed when assigning a disability rating, where service connection has already been established and an increase in the rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion (ROM) measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination and pain on movement, swelling, and deformity or atrophy of disuse. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40; DeLuca, 8 Vet. App. at 205. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology or evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a)(2). Essentially, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran’s back disability is rated under DC 5242-5237. Hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Here, the Veteran’s low back disability is rated as analogous to degenerative arthritis of the spine (DC 5242) and lumbosacral strain (DC 5237). 38 C.F.R. § 4.71a, DCs 5237, 5242. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for DCs 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent disability rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. These criteria are to be applied regardless of whether there are symptoms such as pain (whether or not it radiates), stiffness, or aching in the affected area of the spine, id, and they “are meant to encompass and take into account the presence of pain, stiffness, or aching, which are generally present when there is a disability of the spine.” 68 Fed. Reg. 51,455 (August 27, 2003) (Supplementary Information). Notes appended to the rating formula for diseases and injuries of the spine specify that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Id, Note (2). Provided, however, that, in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion generally recognized by VA. Id, Note (3). Further, the term “combined range of motion” refers to “the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation”; provided, however, that the aforementioned normal ranges of motion for each component of spinal motion, as recognized by VA, are the maximum that can be used for calculation of the combined range of motion, and each range of motion measurement is to be rounded to the nearest five degrees. Id, Notes (2) and (4). Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6) provides that disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Id. Spine conditions rated under DC 5243, for intervertebral disc syndrome, may be rated alternatively based on incapacitating episodes. The criteria provide for a 10 percent rating where intervertebral disc syndrome is manifested with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating was warranted where incapacitating episodes have a total duration of at least two weeks but less than 4 weeks during the past 12 months. “Incapacitating episodes” was defined in Note (1) as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) also allowed the Veteran to be rated separately for musculoskeletal and neurological manifestations under appropriate DCs if it would result in a higher combined evaluation for the disability. The Veteran’s medical records have been associated with the claims file and these show multiple complaints of back pain throughout the appeal period. In December 2014, the Veteran was administered a VA Back Conditions Disability Benefits Questionnaire (Back DBQ). The examiner noted a thoracolumbar strain and spondylolysis of the L5 vertebra diagnoses. The Veteran described flareups which made it unable for him to get out of bed because of the pain. The Veteran’s ROM was noted to be abnormal with forward flexion noted to be from 0 to 50 degrees, extension from 0 to 10 degrees, right lateral flexion from 0 to 15 degrees, left lateral flexion from 0 to 15 degrees, right lateral rotation from 0 to 20 degrees, and left lateral rotation from 0 to 20 degrees. The examiner determined that the Veteran’s ROM itself contributed to functional loss as the Veteran was unable to flex or extend lumbar spine to functional angles necessary for most physical activities that require lifting, carrying objects from ground. The examiner noted the Veteran’s flareup had a weekly frequency, were severe and had a duration of 8 to 12 hours. However, the examiner determined he could not determine whether the Veteran’s flareups significantly limited his functional ability without resulting to mere speculation. Furthermore, the examiner noted the Veteran had a muscle spasm which resulted in an abnormal gait or abnormal spinal contour described as flattening of lumbar lordosis, and localized tenderness resulting in antalgic gait with mild truncal flexion. No guarding was noted nor muscle atrophy. The Veteran was also noted to have normal deep tendon reflexes, normal sensory exams, negative straight leg raising tests, no radiculopathy, no ankylosis of the spine nor any other neurologic abnormality. See Back DBQ of December 2014. In April 2015, the Veteran complained of severe pain lasting a week and not relieved by medication. The Veteran was prescribed some muscle spasm medication. In May 2015 the Veteran complained of constant strong back pain which was controlled with medication. The Veteran explained his low back pain was like a constant ache and at times he had cramping in his legs. In September 2015, the Veteran’s low back pain was noted to be stable and controlled with medication. See medical records for April, May and September 2015. In February 2016, the Veteran complained of low back pain and weakness in his legs. The Veteran explained he had fallen, and he observed cramps and minimal muscle trembling movements. See medical records for February 2016. In May 2016, the Veteran was administered another Back DBQ. The Veteran’s back was noted to have an abnormal range of motion. His forward flexion was noted to be from 0 to 35 degrees, extension from 0 to 10 degrees, right lateral flexion from 0 to 15 degrees, left lateral flexion from 0 to 15 degrees, right lateral rotation from 0 to 15 degrees, and left lateral rotation from 0 to 15 degrees. The examiner did not opine regarding the Veteran’s flareups and how they might have affected his functional ability. The examiner noted the Veteran had muscle spasms, localized tenderness and guarding; all resulting in an abnormal gait or abnormal spinal contour described as “lumbar PVM tenderness”. The Veteran was noted to have normal muscle strength, no muscle atrophy, normal deep tendon reflexes, a normal sensory exam, and negative straight leg raising test. The Veteran was noted to have no radiculopathy, no ankylosis nor any other neurologic abnormalities. See Back DBQ of May 2016. In June 2016, the Veteran complained of back pain irradiating to his right lower extremity, posterior knee and cramps. The Veteran explained his pain was exacerbated with certain movements like forward flexion and squatting. He denied changes in bowel or bladder function and fever. The Veteran reported his medication helped mildly with his pain. See medical records for June 2016. In July and September 2016, the Veteran complained of low back pain which radiated to his right posterior knee. See medical records for July and September 2016. In October 2016, the Veteran was noted to have difficulties to perform basic activities of daily living due to his pain. The Veteran was recommended to obtain certain assistive devices to improve his daily activities, prevent pain exacerbation, decrease effort and increase safety. See medical records for October 2016. In November 2016, the Veteran was referred for aquatic therapy due to muscle weakness and low back pain. The Veteran tolerated the exercises. In this month, the Veteran again complained of low back pain and radiation through the right leg. The Veteran was noted to use a Canadian crutch to support his right lower extremity and without antalgic gait. The Veteran also reported that although his lumbar pain had been exacerbated prior to visiting the hospital, that he felt his back condition had improved as he had been performing stability exercises. See medical records for November 2016. In September 2018 the Veteran reported low back pain exacerbation lasting 3 weeks prior to his hospital visit. He was prescribed pain medication. See medical records for September 2018. In February 2019, the Veteran reported continued low back pain which had improved with physical therapy. See medical records for February 2019. In September 2019, the Veteran was administered a Back Conditions DBQ. In this examination the Veteran’s back was noted to have an abnormal range of motion. His forward flexion was noted to be from o to 35 degrees, extension from 0 to 15 degrees, right lateral flexion from 0 to 20 degrees, left lateral flexion from 0 to 20 degrees, right lateral rotation from 0 to 20 degrees, and left lateral rotation from 0 to 20 degrees. The Veteran reported flareups, several times a month related to activities such as sweeping or mopping which made him rest in bed most of the time until his pain decreased several days later. The examiner estimated the intensity of the Veteran’s pain during a flareup as severe; with an estimated frequency of approximately 3 to 4 times a month and with an estimated duration of approximately 2 or 3 days during a flareup. The examiner further estimated the Veteran’s ROM during a flareup as follows: flexion from 0 to 15 degrees, extension from 0 to 5 degrees, right lateral flexion from 0 to 10 degrees, left lateral flexion from 0 to 10 degrees, right lateral rotation from 0 to 10 degrees, and left lateral rotation from 0 to 10 degrees. No guarding nor muscle spasms were noted. No muscle atrophy, ankylosis, or any other neurologic abnormalities were noted. See Back DBQ of September 2019. Based on the evidence above discussed the Board finds that prior to September 9, 2019, the Veteran’s disability did not present itself with forward flexion of the thoracolumbar spine limited to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. The Board notes that the Veteran’s medical records reflect he sought medical care for his back pain during the appeal period however these medical records also show that the Veteran reported improvement of his symptoms in 2016 and in 2019. Additionally, although the Veteran was noted to suffer from flareups of his condition prior to September 2019; these flareups were not estimated in terms of ROM limitations and the most probative evidence of record does not support that the Veteran’s flareups rose to the severity of the next higher disability rating prior to September 2019. Moreover, the Board notes that although the Veteran reported having to stay in bed during bad flareups; this bed rest was not noted to be prescribed by a physician. Therefore, a higher rating under DC 5243, for intervertebral disc syndrome, applying the alternate disability rating criteria for incapacitating episodes is not for application in this case. Accordingly, the Board finds that the preponderance of the evidence is against finding that prior to September 9, 2019 the Veteran’s back disability severity most closely approximated the rating criteria for the next higher rating of 40 percent and the claim for a disability rating in excess of 20 percent prior to September 9, 2019 must be denied. For the period following September 9, 2019, the Veteran’s disability has presented with flareups which limit the Veteran’s forward flexion to 15 degrees approximately. Based on this clinical finding by the VA examiner in the September 2019 VA Back DBQ, the Veteran was granted a disability rating of 40 percent from September 9, 2019. A disability rating of 50 percent following September 9, 2019 is not warranted as the evidence of record does not show the Veteran’s back disability has resulted in unfavorable ankylosis of the entire thoracolumbar spine. REASONS FOR REMAND 1. Entitlement to service connection for a right shoulder disability is remanded. 2. Entitlement to service connection for a left shoulder disability is remanded. The Veteran asserts that his current bilateral shoulder disabilities are related to his service. In specific the Veteran points to an in-service incurrence consisting of being thrown to the ground by a drill instructor. In September 2019, the Veteran was administered a Shoulder and Arm Condition Disability Benefits Questionnaire (Shoulder DBQ). In this examination, the Veteran was diagnosed with bilateral shoulder impingement syndrome and was noted to have a bilateral shoulder degenerative arthritis. The Veteran explained that since 2004, he had suffered bilateral shoulder pain and had difficulty with overhead activities. Both shoulders were noted to have abnormal range of motion. The examiner did not emit an opinion regarding the nature and etiology of the Veteran’s bilateral shoulder disabilities. Accordingly, the Board finds a remand is necessary to obtain an addendum medical opinion regarding the etiology of the Veteran’s condition. 3. Entitlement to service connection for a neck disability is remanded. The Veteran asserts that his neck disability is related to his service. In September 2019, the Veteran was administered a VA Neck (Cervical Spine) Conditions Disability Benefits Questionnaire (Neck DBQ). The examiner noted a diagnosis of cervical strain and cervical myositis. The Veteran reported having constant neck pain since 2004. The Veteran was noted to have an abnormal range of motion. The examiner opined that the Veteran’s neck disability was less likely than not incurred in or caused by the Veteran’s service. In favor of his determination, the examiner noted that the Veteran’s current cervical condition was diagnosed in the year 2016 when he started to complain of neck pain. The Board finds this medical opinion inadequate as it does not note whether the Veteran’s lay statements regarding an in-service incident of being thrown to the ground by his drill instructor was considered or discarded. Accordingly, the Board finds a remand is necessary so that an addendum medical opinion that addressed the Veteran’s lay statements can be obtained. The matters are REMANDED for the following action: 1. Update medical records. 2. Obtain an addendum medical opinion from an appropriate clinician to determine the nature and likely etiology of the Veteran’s bilateral shoulder disability. a. The examiner is asked to opine whether the Veteran’s bilateral shoulder disability is at least as likely as not (i.e., a 50 percent or greater probability) related to his service. The examiner must address the Veteran’s lay statements and the described in-service incident of being thrown to the ground by a drill instructor. 3. Obtain an addendum medical opinion from an appropriate clinician to determine the nature and likely etiology of the Veteran’s neck disability. a. The examiner is asked to opine whether the Veteran’s neck disability is at least as likely as not (i.e., a 50 percent or greater probability) related to his service. b. If the answer to the previous question is negative, the examiner is asked to opine whether the Veteran’s neck disability is caused by or aggravated by his service-connected back disability. When emitting his opinion, the examiner is asked to consider the Veteran’s lay statements and the described incident in service of being thrown to the ground by a drill instructor. The claims file and a copy of this remand must be made available to the examiner and the examiner should note in the examination report that the claims folder and the remand have been reviewed. All addendum medical opinions must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). The examination should include any diagnostic testing or evaluation deemed necessary. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, furnish the Veteran and his representative a supplemental statement of the case (SSOC) which considers all evidence added since the SOC and return the case to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Gonzalez-Maldonado 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.