Citation Nr: 21004820 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 15-04 109 DATE: January 28, 2021 REMANDED Entitlement to service connection for a left shoulder disability is remanded. REASONS FOR REMAND The Veteran had active duty service from September 1984 to July 1990, and from January 1991 to March 1991. In December 2018 and September 2020, the Board remanded the above issue for additional development. 1. Entitlement to service connection for a left shoulder disability is remanded. The Veteran contends that the Veteran’s left shoulder disability is related to injuries he sustained during service as well as the physical activities associated with his military occupational specialty (MOS) of infantryman. Specifically, the Veteran reported that he had to carry heavy rucksacks while in service and that he has had constant pain in the left shoulder that has progressed. Additionally, in his April 2018 hearing, the Veteran testified that he was in infantry as an assistant gunner, and, as a gunner, he had to carry 80 pounds of equipment, which included the tripod and extra amounts of ammunition. See April 2018 hearing transcript. First, with respect to a diagnosis, the November 2019 VA examiner diagnosed the Veteran with left shoulder strain and rotator cuff tendonitis. The October 2020 VA examiner also noted that the Veteran has a left shoulder strain and tendonitis. With respect to a nexus, the November 2019 VA examiner found that the Veteran’s left shoulder disability was not related to service. The examiner noted that there is a lack of sufficient information to confirm a left shoulder injury during active service. The October 2020 VA examiner opined that the Veteran's left shoulder condition, to include strain and tendonitis, is less likely than not (less than 50 percent probability) incurred in or caused by service. The examiner noted that the Veteran reported having shoulder pain in 2009, and his primary care provider endorsed the same findings. The examiner reasoned that his service records are absent for a chronic left shoulder condition, and he denied shoulder pain during his separation exam in 1991. The examiner also noted that his VA treatment records endorse shoulder pain since 2009, which is 18 years after discharge from service. The examiner reasoned that, considering shoulder pain was not noted until 18 years post discharge, it is unlikely that his shoulder pain is related to military service. Given the absence of chronic left shoulder pain noted in service or within a year of discharge from service, the examiner concluded that his current left shoulder condition is less likely than not related to service and more likely related to wear and tear, advanced age, and overuse after service. The Board finds both the November 2019 and October 2020 VA opinions inadequate, as neither the November 2019 nor the October 2020 VA examiners addressed the Veteran’s specific lay statements that his left shoulder disability is due to (1) physical activities as an infantryman, (2) carrying heavy rucksacks, and/or (3) carrying 80 pounds of equipment while he was a gunner, which included the tripod and extra amounts of ammunition or his reports of shoulder pain since service. While the Board regrets the additional delay, a remand is necessary to obtain another VA opinion on the nature and etiology of the Veteran’s left shoulder disability. The matter is REMANDED for the following action: 1. Obtain a VA opinion to determine the nature and etiology of his left shoulder disability. The claims file must be made available and must be reviewed by the examiner. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s left shoulder disability was incurred in service, or is otherwise related to service. The examiner is advised that all lay statements of record should be considered in the rendered opinion, including lay statements of shoulder pain since service. The examiner is also specifically asked to address the Veteran’s statements that his left shoulder disability is due to (1) physical activities as an infantryman, (2) carrying heavy rucksacks, and/or (3) carrying 80 pounds of equipment while he was a gunner, which included the tripod and extra amounts of ammunition. 2. After completing the above action, the claim must be readjudicated. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. E. Grossman, 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.