Citation Nr: 20026025 Decision Date: 04/15/20 Archive Date: 04/15/20 DOCKET NO. 14-33 918 DATE: April 15, 2020 REMANDED Entitlement to service connection for cervical spine disorder is remanded. Entitlement to service connection for right shoulder disorder is remanded. Entitlement to service connection for left shoulder disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1981 to September 1986. These matters come before the Board of Veterans’ Appeals (Board) on appeal from April 2014 and May 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously before the Board in May 2018. 1. Entitlement to service connection for cervical spine disorder Remand is required to obtain an additional VA medical opinion. A May 2019 VA examination found that the Veteran’s cervical spine disability was less likely than not related to service, citing as part of its rationale that the Veteran’s in-service muscle strain resolved and the Veteran did not seek treatment “from 1986 until well-after 2000.” The Veteran’s VA medical center (VAMC) records, however, include a December 1998 record which noted “His back pain is usually lower but on occasion is in upper back and neck” as well as a March 2002 record which indicated the Veteran had “chronic low back pain, now moving to head neck, shoulders.” Moreover, the May 2018 Decision and Remand directed the VA examination to consider the Veteran’s lay reports regarding onset and continuity of his asserted neck symptoms. Because this was not done, an additional VA medical opinion is required on remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that the Board errs as a matter of law when it fails to ensure compliance with its remand orders). 2. Entitlement to service connection for right shoulder disorder is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for right shoulder disorder because no VA examiner has opined whether the Veteran’s right shoulder disability is related to in-service shoulder pain. A May 2019 VA examination stated in its rationale that “Review of the [service treatment records] do [sic] show multiple evaluations for ongoing low back pain but no mention ever of any shoulder pain or injury while the Veteran was on active duty.” There are two references to shoulder pain in January 1985 and October 1985 service treatment records, however. In addition, the May 2019 VA examination indicated that the Veteran reported frozen shoulder on the right “but there is no formal evaluation or treatment of this condition in the VAMC records.” March 2019 VAMC records diagnosed both right shoulder rotator cuff tendinitis and right frozen shoulder, however. Thus, an additional VA examination is necessary on remand to consider service treatment records and determine the Veteran’s current right shoulder disability. 3. Entitlement to service connection for left shoulder disorder is remanded. The Board cannot make a fully informed decision on the issue of entitlement to service connection for left shoulder disorder because no VA examiner has opined whether the Veteran’s left shoulder disability is related to in-service shoulder pain. A May 2019 VA examination stated in its rationale that “Review of the [service treatment records] do [sic] show multiple evaluations for ongoing low back pain but no mention ever of any shoulder pain or injury while the Veteran was on active duty.” There are two references to shoulder pain in January 1985 and October 1985 service treatment records, however. Thus, an additional VA examination is necessary on remand to consider service treatment records. 4. Entitlement to a TDIU is remanded. The RO failed to address the issue of entitlement to a TDIU as directed in the May 2018 Decision and Remand. This must be accomplished on remand. See Stegall, 11 Vet. App at 271. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s cervical spine disability at least as likely as not (a.) Had its onset in service. (b.) Was manifested by arthritis in the year immediately following service. (c.) Is otherwise the result of a disease or injury in service. The clinician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the clinician rejects the Veteran’s reports of symptomatology, the clinician must provide a reason for doing so. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any shoulder disabilities. The examiner must opine whether any shoulder disability at least as likely as not (a.) Had its onset in service. (b.) Was manifested by arthritis in the year immediately following service. (c.) Is related to an in-service injury, event, or disease, including the shoulder pain documented in January 1985 and October 1985. If the Veteran’s cervical spine disability is deemed service connected, determine whether any shoulder disability is at least as likely as not (d.) Proximately due to cervical spine disability. (e.) Aggravated beyond its natural progression by cervical spine disability. 3. Adjudicate the issue of TDIU flagged in the May 2018 Decision and Remand. M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board W. Ripplinger, 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.