Citation Nr: 20026097 Decision Date: 04/15/20 Archive Date: 04/15/20 DOCKET NO. 19-14 979 DATE: April 15, 2020 REMANDED Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a right knee disability is remanded. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a neck disability is remanded. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a left ankle disability is 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 low back disability is remanded. REASONS FOR REMAND The Veteran had active duty for training (ACDUTRA) from September 1981 to January 1982. He was a member of the Georgia Army National Guard from April 1981 to July 1986 with periods of ACDUTRA and inactive duty training (INACDTURA). This matter comes before the Board of Veterans’ Appeals on appeal from an August 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). All Claims The clinical records reflect that the Veteran applied for Social Security Disability benefits (see April 2012 record); VA has a duty to attempt to obtain all federal records which may be relevant. Bilateral Shoulder disability The Veteran asserts that his bilateral shoulder condition began during his time in service, to include in July 1985 when he was involved in a motor vehicle accident. The STRs are negative for shoulder complaints. They note that in October 1981, he had a complaint of the neck after his backpack hit the back of his head when he bent down; it was noted that there would be consultation for bracing for rotation, and shoulder shrugging, but they are negative for a shoulder injury. Subsequently the Veteran was noted to play basketball (see May 1983 STR), which the Board can reasonably find includes movement of the shoulders. With regard to the July 1985 accident, the Statement of Medical Examination and Duty Status notes that the Veteran was involved in an accident on July 29, 1985 and examined that same date. It was noted that he had been thrown against the side of a 2 ½ ton truck striking his head and neck. The report is negative for complaints of the shoulder. A next-day July 30, 1985 STR notes that that the Veteran was seen for an x-ray of the skull; it is negative for a shoulder complaint. A September 1985 Report of Medical History for periodic purposes reflects that the Veteran reported that he was in good health. Notably, he specifically denied a painful or trick shoulder. The earliest clinical record of a shoulder disability is many years post service. A March 2001 private record notes complaints of right arm pain for one month in duration. It was noted that the pain was in the right shoulder and went into the right side of the neck. It was noted that he was “not able to do the work with throwing a piece of wood because of the pain and discomfort.” It was noted that he had possible cervical disc disease. The Board is unsure of the exact occupation of the Veteran, but he was noted in a record to work in a Home building company, and for a large manufacturing company (G.P.). The earliest complaint of the left shoulder is from June 2009; the Veteran reported back discomfort from the left shoulder on the back side down to the hip which “has been going off and on for years”. The Board finds, at this time, that any contention as to continuity of symptom since service is less than credible given the record as a whole, to include the lack of STRs and the Veteran’s specific denial in 1985. Thus, the August 2017 examination report associated with the claims file lacks probative value as the opinion was based on chronic and continuous treatment and care since service. If SSA records are indicative that the Veteran has a shoulder disability related to service, a VA examination is warranted. Bilateral Knee Disability The Veteran contends that he injured his knees in a July 1985 motor vehicle accident and has had bilateral knee pain ever since then. The Veteran’s STRs are negative for a complaint of the knees with regard to the July 1985 accident. A May 1983 STR notes that the Veteran reported that both knees have given him trouble in the past and that his right knee had been bothering him since playing basketball the prior evening. The Board finds it notable that the Veteran referred to the knees giving him trouble in the past and that he had been on ACDUTRA for only two weeks. The Veteran subsequently denied a trick or locked knee, joint deformity, and arthritis in September 1985 on his Report of Medical History. A January 1999 private record notes that the Veteran complained of pain which had moved to the left knee; it was noted that he had arthritis. A June 2007 private record notes increasing pain in his right knee. It was noted that for the previous couple of weeks, the Veteran had been “working very hard and having overtime at 100 to 120 hours per work”; he was noted to have degenerative arthritis of the right knee. A November 2014 VA examination report reflects that the Veteran reported pain in both knees for 15 years, or since 1999, which is more than a decade after separation from service. SSA record may provide evidence to reopen the Veteran’s claim with regard to the right knee, and if the SSA records, or additional evidence, reflects that the Veteran has a knee disability causally related to service, a VA examination would be warranted. Back Disability The Veteran’s STRs are negative for back complaints. His September 1985 Report of Medical History reflects that he denied recurrent back pain. The earliest post service evidence of a back disability is in August 1997, at which time the Veteran reported that he has had back pain off and on for “sometime”. If the SSA records indicate that the Veteran may have a back disability causally related to service, an examination would be warranted. Neck Disability The Veteran asserts that his neck pain had its onset in service, particularly after a July 1985 motor vehicle accident. Service records indicate the Veteran “was thrown against side of 2 ½ ton truck striking his head and neck.” STRs indicate complaints of neck pain, swelling and stiffness. The Veteran was provided a VA examination in November 2014. The examiner noted degenerative arthritis of the cervical spine and the Veteran’s reports of constant pain. The examiner found that the Veteran’s neck condition was less likely than not related to the claimed in-service injury, stating that the degenerative changes of his cervical spine are part of the aging process. In addition, the examiner stated that a correlation between the cervical strain noted in service and the Veteran’s current condition could not be found. SSA records may provide pertinent evidence to allow for the claim to be reopened. Bilateral Ankle Disability The Veteran’s STRs are negative for ankle complaints. His September 1985 Report of Medical History reflects that he denied pertinent complaints. SSA records may provide pertinent evidence to allow for the claim for the right ankle to be reopened. In addition, if the SSA records indicate that the Veteran may have an ankle disability causally related to service, an examination would be warranted. The matters are REMANDED for the following action: 1. Attempt to obtain the Veteran’s records from the Social Security Administration, to include all medical records used in making a disability determination. 2. Thereafter, if the clinical records (or other competent and credible evidence) reflect that the Veteran may have a disability which is causally related to service, he should be scheduled for an examination. Any examination must consider the pertinent evidence of record, to include: a.) the Veteran’s dates of ACDUTRA and INACDTURA; b.) the STRs, to include the September 1985 Report of medical history; c.) the Veteran’s civilian and post-service employment, and d.) the earliest post-service clinical evidence of a disability. (Continued on the next page)   The Veteran’s lay statement as to continuity of symptoms should not be considered unless supported by the record. 00 An adequate rationale should be provided for any opinion offered. T. WISHARD Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Ariasaif, 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.