Citation Nr: 21000764 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 15-44 506 DATE: January 6, 2021 REMANDED Entitlement to service connection for a bilateral shoulder disability, to include nerve impingement, is remanded. Entitlement to service connection for a back or neck disability, to include nerve impingement, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1977 to January 1997. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared for a hearing before the undersigned Veterans Law Judge in October 2018. The hearing transcript is associated with the claims file. The appeal was last remanded by the Board in May 2019 for additional development. Regrettably, more development is still necessary. 1. Entitlement to service connection for a bilateral shoulder disability, to include nerve impingement, is remanded. In July 2019, additional private treatment records were submitted in support of the Veteran’s claim including a November 2018 private treatment record. The November 2018 private treatment record explained that the Veteran had a long history of neck pain that had slowly worsened and resulted in the Veteran’s reports of stiffness and pain in his posterior cervical region and involving his left paraspinal region and trapezius. The record also noted that the Veteran’s symptoms may be related to his carpal tunnel syndrome. A VA opinion was obtained in October 2020 without an in-person examination of the Veteran. The October 2020 VA opinion noted that the Veteran had abnormal range of motion of his shoulders bilaterally; pain on flexion, external rotation, abduction, and internal rotation bilaterally; and significantly limited functional ability bilaterally with repeated use over time due to pain. The October 2020 VA opinion determined, however, that the Veteran did not have a shoulder disability. In addition, no imaging studies of the Veteran’s shoulders were obtained, and no diagnostic testing was performed. The VA physician did not provide any explanation for the lack of a diagnosis despite the Veteran’s recorded symptoms. The Board finds that the October 2020 VA opinion is inadequate. In addition, a VA opinion was also obtained in October 2020, without an in-person examination nor diagnostic testing, to evaluate any peripheral nerve conditions. The October 2020 VA opinion noted that the Veteran had a diagnosis of cervical spine spondylosis/stenosis with left upper extremity radiculopathy. The VA physician noted that the Veteran had tingling in his left arm and hand but then proceeded to note that the Veteran did not have any symptoms attributable to a peripheral nerve condition. The VA examiner failed to address the November 2018 private treatment record addressing the relation of the Veteran’s back, neck, and shoulder disabilities to his alleged carpal tunnel syndrome. The examiner did not address whether the Veteran had a diagnosis of carpal tunnel syndrome etiologically related to service which could be the cause of the Veteran’s shoulder symptoms. Accordingly, remand for a new, in-person examination is required to address the recently obtained private treatments records and to adequately evaluate the Veteran’s symptoms and determine the etiology for any left or right shoulder disability. 2. Entitlement to service connection for a back or neck disability, to include nerve impingement, is remanded. As previously stated, in July 2019, additional private treatment records were submitted in support of the Veteran’s claim including a November 2018 private treatment record. The November 2018 private treatment record noted that the private physician believed that Veteran’s cervical spine symptoms were “mainly secondary to carpal tunnel”. VA opinions were obtained in October 2020, without an in-person examination of the Veteran, addressing the Veteran’s claimed back, neck and peripheral nerve disabilities. The October 2020 VA opinion noted that the Veteran had a diagnosis of cervical spine spondylosis/stenosis with left upper extremity radiculopathy. The VA physician noted that the Veteran had tingling in his left arm and hand but then proceeded to note that the Veteran did not have any symptoms attributable to a peripheral nerve condition. Again, the VA examiner failed to address the November 2018 private treatment record relating the Veteran’s back, neck, and shoulder disabilities to carpal tunnel syndrome. Accordingly, remand for a new, in-person examination is required to address the recently obtained private treatments records and to adequately evaluate the Veteran’s claimed back and neck disabilities and determine the etiology for any such disability. By this remand, the Board makes no determination, express or implied, concerning the credibility of the Veteran’s statements and contentions. The matters are REMANDED for the following action: 1. Schedule a VA examination to determine the nature and etiology of the Veteran’s bilateral shoulder disabilities. The Veteran’s claims file must be made accessible to the examiner in conjunction with the examination. This review should include the Veteran’s service treatment records, post-service medical treatment records including the November 2018 private treatment record, the October 2018 hearing transcript and the assertions of the Veteran and his representative, along with any other information the medical professional deems pertinent. A note that this information was reviewed should be included in the opinion. All necessary tests, to include electrodiagnostic studies, should be conducted, and the findings reported in detail. (a.) For each identified shoulder disability, including any nerve impingement disability impacting the Veteran’s shoulders including carpal tunnel syndrome, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or more probability) etiologically related to service. (b.) A complete rationale for all findings and conclusions must be provided. (c.) The examiner 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. 2. Schedule a VA examination to determine the nature and etiology of the Veteran’s back and neck disabilities. The Veteran’s claims file must be made accessible to the examiner in conjunction with the examination. This review should include the Veteran’s service treatment records, post-service medical treatment records including the November 2018 private treatment record, the October 2018 hearing transcript and the assertions of the Veteran and his representative, along with any other information the medical professional deems pertinent. A note that this information was reviewed should be included in the opinion. All necessary tests, to include electrodiagnostic studies, should be conducted, and the findings reported in detail. (a.) For each identified shoulder back or neck disability, including any nerve impingement disability impacting the Veteran’s shoulders including carpal tunnel syndrome, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or more probability) etiologically related to service. (b.) A complete rationale for all findings and conclusions must be provided. (c.) The examiner 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. 3. Then, readjudicate the claim. If the determination of the claim remains unfavorable to the Veteran, then issue a Supplemental Statement of the Case and afford him a reasonable period of time to respond before returning the case to the Board. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Palombi, 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.