Citation Nr: 21001351 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 14-29 340 DATE: January 7, 2021 REMANDED Entitlement to service connection for a right shoulder disorder, claimed as fracture of the right clavicle, is remanded. REASONS FOR REMAND The Veteran had active duty service from September 1977 to September 1981. He testified before the undersigned Veterans Law Judge (VLJ) at a videoconference hearing in January 2020. A transcript of the hearing is of record. Entitlement to service connection for a right shoulder disorder is remanded. In August 2020, the Board remanded the Veteran’s claim to obtain additional VA medical opinion. Opinions were obtained in September 2020 and October 2020. However, they are incomplete. As noted by the RO in a September 2020 Deferred Rating Decision, the Board requested the examiner to consider the Veteran’s reports of right shoulder pain since 1981, almost immediately following service. The Board also requested the examiner to address whether the Veteran’s currently diagnosed right shoulder disorder is the type of disorder that would develop as a result of a right clavicle fracture or similar injury and also to opine as to the likely etiology of the Veteran’s current right shoulder disorder, if not due to service, if possible. In October 2020, the examiner explained the causes of shoulder impingement and osteoarthritis generally but did not discuss how that information relates to this Veteran’s history. The opinions also do not address whether the currently diagnosed disorders are the type that would develop as a result of a right shoulder injury 33 years prior. As such, remand is required for additional VA medical opinion. The matters are REMANDED for the following action: 1. If possible, obtain a VA medical opinion from another VA examiner addressing the etiology of the Veteran’s right shoulder disorder. The need for an in-person examination is left to the discretion of the examiner. The Veteran contends that residuals from a right clavicle injury were incurred in service and his right clavicle symptoms have continued since service. Although his service treatment records largely document injury to the left shoulder, he has consistently stated that he also injured his right shoulder in the motorcycle accident which occurred while in service. As previously noted by the Board, the December 2016 VA examiner seemed to suggest that the Veteran’s current right shoulder disorder was not related to service because he was pointing to an area that was painful that would not be the result of a right clavicle fracture. The Veteran is currently service-connected for fracture of the distal left clavicle. The October 2020 VA examination report shows that the Veteran has a diagnosis of distal fracture left clavicle; however, his diagnoses of the right shoulder are shoulder impingement syndrome and degenerative arthritis. In December 1981, three months post-service, the Veteran filed a claim for service connection for his bilateral shoulders. He specifically stated, “fractured right and left clavicle – March 1978.” He reported treatment from March 1978 to May 1978 and has maintained that both shoulders have been painful since service. As noted by the Board in its August 1983 decision, on VA examination in April 1983, the Veteran complained of pain in both shoulders. He had full range of motion in both shoulders and there was a nontender callus palpable on the outer third of the left clavicle. The right clavicle revealed no evidence of a past or present fracture of that area. The examination stated “by present x-rays there is no evidence of fracture of the right clavicle. There is tendinitis of both shoulders.” The examiner should also consider the September 1989 statement made by the Veteran whereby he stated: “I would like to point out that this is the second medical veterans doctor that has told me that my left clavicle will never be the same. I informed him that I still felt pain whenever I move in any rapid movement or use it to do any lifting, or when I am typing in a stationary position, also I can hear it pop when rotating it, also I am in constant pain when I sleep because I find that I’ll roll over it. Furthermore, my right shoulder does hurt when I lift it straight up.” In his statement in September 1989, he did not endorse the same level of impairment for both shoulders. Instead, he reported far worse symptomatology in the left, but did indicate some level of impairment in the right shoulder as well. After considering all of the evidence noted above, as well as the entire claims file, the examiner is asked to opine whether the Veteran’s right shoulder disorder is at least as likely as not related to service. In so opinion, the examiner is asked to provide an opinion stating whether or not the Veteran’s currently diagnosed right shoulder disorder is the type of disorder that would develop as a result of trauma to the right shoulder during service, with no evidence of fracture of the right shoulder on X-ray taken approximately 1.5 years post-service. An opinion which outlines the medical findings related to the Veteran’s right shoulder, considers his lay statements related to having pain in his right shoulder since service, and explains why diagnoses of right shoulder acromioclavicular joint arthritis and impingement syndrome approximately 33 years post-service are not consistent with having been caused by an in-service motorcycle accident, would be of considerable help to the Board. A complete rationale for any medical opinion rendered must be provided. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Martha R. Luboch, 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.