Citation Nr: 21002098 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 18-49 160 DATE: January 12, 2021 REMANDED Entitlement to service connection for a left shoulder disability, to include as due to frostbite, is remanded. Entitlement to service connection for a right shoulder disability, to include as due to frostbite, is remanded. Entitlement to service connection for a left knee and leg disability, to include as due to frostbite, is remanded. Entitlement to service connection for a right knee and leg disability, to include as due to frostbite, is remanded. Preliminary Matters The Veteran had honorable active duty service with the United States Army from April 1953 to November 1957. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an October 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In November 2020, the Veteran and his niece testified at a virtual Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the Veteran’s electronic claims file. REASONS FOR REMAND Although further delay is regrettable, the Board finds that a remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Entitlement to service connection for a left shoulder disability, to include as due to frostbite, is remanded. See Argument Below 2. Entitlement to service connection for a right shoulder disability, to include as due to frostbite, is remanded. See Argument Below 3. Entitlement to service connection for a left knee and leg disability, to include as due to frostbite, is remanded. See Argument Below 4. Entitlement to service connection for a right knee and leg disability, to include as due to frostbite, is remanded. At the outset, the Board notes that the Agency of Original Jurisdiction (AOJ) has verified that the Veteran’s service treatment records and the majority of his personnel records are unavailable and are presumed to have been destroyed in a fire at the National Personnel Records Center (NPRC) in 1973. Thus, further efforts to obtain the Veteran’s service treatment records and personnel records would be futile. Additionally, the Board notes that minimal VA treatment records are of record. Accordingly, any missing VA treatment records must be sought on remand. Also, during the November 2020 Board hearing, the Veteran indicated that he was diagnosed with frostbite in 2008 or 2009 by Dr. T.G., a private physician. See November 2020 Hearing Transcript at pg. 5. However, based on a review of the claims file, it does not appear that these treatment records have been associated with the record. As these medical records are potentially relevant to the instant issues on appeal, the RO must take all appropriate action to locate and obtain these outstanding records. Thus, the Board finds that the RO should make an attempt to obtain these private medical records. The Veteran is invited to provide these records himself. Furthermore, the record reflects that the Veteran has not been afforded a VA examination in connection with his claimed disabilities, and no opinions as to whether these claimed disabilities are related to the Veteran’s active service are of record. The Board notes that in April 2017 private disability benefits questionnaires (DBQ), Dr. J.F. provided diagnoses of bilateral shoulder impingement syndrome, rotator cuff tendonitis, glenohumeral joint osteoarthritis. He also provided a diagnosis of bilateral knee joint osteoarthritis. Dr. J.F. did not provide an opinion as to whether these diagnosed conditions were related to the Veteran’s period of active service. During the November 2020 Board hearing, the Veteran testified that had pain in his knees and shoulders during service. In light of the evidence of record, the Veteran may have current disabilities related to the shoulders and knees that may be associated with service. As the Veteran has not been afforded a VA examination in connection with any of these claims, the Board finds that a remand for a VA examination for each claimed disability is warranted. The Board notes that the examiner should consider the outstanding treatment records as identified herein. The matters are REMANDED for the following action: 1. Identify and obtain any outstanding VA and private treatment records, to include the 2008/2009 private treatment records from Dr. T.G., that are not already associated with the claims file. If any record identified cannot be obtained, the Veteran and his representative should be notified of this in writing, to include all efforts taken by VA to attempt to obtain any such record. The Veteran should also be offered the option to provide any such record himself. 2. After obtaining any outstanding records, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any knee condition. If an examination cannot be scheduled at a location to which the Veteran can safely travel, or if health considerations make the scheduling of an in-person examination not possible, the AOJ should consider whether other virtual options, to include telehealth interviews or examinations are possible. If virtual alternatives are not feasible or possible, the AOJ should indicate as much, and medical opinions based on review of the Veteran’s claims file should be obtained, in lieu of an in-person or virtual examination, addressing the etiology of the Veteran’s claimed disability. The examiner must state an opinion as to the following: (a) Identify any and all disabilities pertaining to the Veteran’s bilateral knees. (b) For any currently diagnosed knee disability, the examiner should provide an opinion as to whether it is at least as likely as not related to the Veteran’s military service, to include as a result of the alleged in-service cold weather injury. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 3. Then, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any shoulder condition. If an examination cannot be scheduled at a location to which the Veteran can safely travel, or if health considerations make the scheduling of an in-person examination not possible, the AOJ should consider whether other virtual options, to include telehealth interviews or examinations are possible. If virtual alternatives are not feasible or possible, the AOJ should indicate as much, and medical opinions based on review of the Veteran’s claims file should be obtained, in lieu of an in-person or virtual examination, addressing the etiology of the Veteran’s claimed disability. The examiner must state an opinion as to the following: (a) Identify any and all disabilities pertaining to the Veteran’s bilateral shoulders. (b) For any currently diagnosed shoulder disability, the examiner should provide an opinion as to whether it is at least as likely as not related to the Veteran’s military service, to include as a result of the alleged in-service cold weather injury. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 4. After completing all indicated development, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If any benefit sought on appeal is not granted, the Veteran and his representative should be provided a Supplemental Statement of the Case (SSOC) and afforded the requisite opportunity to respond before the case is remanded to the Board. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Y. MacDonald, 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.