Citation Nr: 21062578 Decision Date: 10/08/21 Archive Date: 10/08/21 DOCKET NO. 18-23 311 DATE: October 8, 2021 REMANDED Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1983 to October 1986, with additional service in the Army National Guard. The matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2015 and April 2016 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In March 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the proceeding is associated with the claims file. The Board regrets further delay, but additional development is necessary before the matter can be adjudicated. Entitlement to service connection for a neck disability The Veteran contends that that he hit his head on the slope of a pool during active service and injured his neck. He states that while he was taken to the hospital on base, no MRI was taken at the time. He further states that a post-service MRI revealed that he broke his neck, which he attributes to this in-service incident. The Veteran service treatment records (STRs) reveal that he sought treatment for a head injury sustained in a pool. He reported neck, head, and shoulder pain; he was assessed with blunt trauma to the head and cervical strain. The Veteran was afforded a VA examination in February 2018, in which he was diagnosed with spondylitis cervical spine C7-T1; central canal stenosis C5-6; osteophytes C5, C6-7, C3-4; disc herniation C5-6; and bulging disc C4-5. The examiner opined that the Veteran's neck disability was less likely than not incurred in or related to active service. She reasoned that the condition was acute during service and that there was no evidence of chronicity of care. The Board finds that the February 2018 VA medical opinion is inadequate as the examiner failed to provide sufficient rationale for her conclusion that the Veteran's neck disability is not etiologically related to service. Additionally, the examiner failed to consider the Veteran's lay statements regarding onset and duration of his symptoms. Accordingly, the Board finds that remand is necessary to obtain an addendum medical opinion. Entitlement to service connection for a back disability The Veteran contends that his strained his back while lifting heavy tents during active service and that he re-injured his back in May 1992 during training for the Army National Guard when he fell and landed on concrete. He states that he has continued to have back pain since this incident and treated the condition with over-the-counter medication on a regular basis. The Veteran's STRs indicate that he reported having back pain and spasms after squatting with weights in March 1986; a provisional diagnosis of lumbar strain was given. The records related to the pool incident note complaints of pain in the lower back. In August 1986, the Veteran reported having tailbone pain. The Veteran's Army National Guard personnel records and STRs indicate that while completing the Leadership Reaction Course in May 1992, the Veteran slipped and hit his side on a concrete pillar. His medical records reveal that he was diagnosed with left flank trauma. The Veteran was afforded a VA examination in October 2015, in which he was diagnosed with degenerative disc changes. The examiner opined that the Veteran's back disability was less likely than not incurred in or caused the claimed in-service injury, event, or illness. The examiner reasoned that the Veteran's STRs are silent for diagnosis or treatment of the actual lumbar spinal cord and the Veteran was never diagnosed with a lumbar spine disorder during active military service. The Board finds that the October 2015 VA medical is inadequate as the examiner's opinion is largely based on the absence of a diagnosis during active service. See Dalton v. Nicholson, 21 Vet. App. 23, 40 (2007). Additionally, the examiner did not address the Veteran's May 1992 injury, which occurred during a period of active duty for training (ACDUTRA). Accordingly, remand is warranted to obtain a supplemental medical opinion regarding the nature and etiology of the Veteran's back disability. Entitlement to service connection for a right shoulder disability The Veteran contends that his right shoulder disability is due to an injury he sustained during his service in the Army National Guard while playing football. He alleges that he was evaluated with a partially torn rotator cuff and has continued to have shoulder problems since. The Veteran's STRs indicate that he reported hurting his right shoulder doing push-ups and reinjuring his shoulder while playing football in January 1991; he was diagnosed with rotator cuff strain. February 1991 physical profiles indicate that the Veteran had right shoulder rotator cuff sprain and right shoulder tendonitis. In an April 1991 report of medical history, the Veteran reported having a painful or "trick" shoulder. The Veteran's military personnel records indicate that he had ACDUTRA service from January 3, 1991 to February 22, 1991. An October 2015 VA examiner opined that the Veteran's right shoulder disability was less likely than not incurred in or caused by the claimed in-service injury or event. She reasoned that the Veteran was not diagnosed with a rotator cuff tear during active military service periods. She further noted that the first documented right shoulder complaints after 1991 was in March 2012. At that time, an MRI revealed partial tear of the rotator cuff and osteoarthritis of right shoulder. Thus, the examiner concluded that because the Veteran was never diagnosed per medical personnel during activation with right shoulder rotator cuff tear or strain, it is less likely than not that his right shoulder disability is due to or caused by tendonitis he experienced 21 years earlier. The Board finds that remand is necessary to obtain a supplemental medical opinion regarding the nature and etiology of the Veteran's right shoulder disability as there is no adequate medical opinion on which to adjudicate the matter. Here, the October 2015 VA examiner did not provide an adequate rationale for her conclusion that the Veteran's right shoulder disability is not etiologically related to service. Additionally, the examiner failed to consider the Veteran's statements regarding onset and duration of symptoms and largely based her opinion on the absence of treatment post-service. Entitlement to service connection for a left knee disability The Veteran contends that his left knee disability is due to active service. Specifically, he contends that his left knee disability began in service and has continued since service. The Veteran's STRs reveal complaints and treatment for left knee pain in August 1984, January 1985, February 1985, March 1985, April 1985, May 1985, and July 1985. He was diagnosed with chondromalacia and patella femoral syndrome. The Veteran was afforded a VA examination in October 2015, in which he was diagnosed with left knee osteoarthritis. The examiner opined that the Veteran's left knee disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that patellofemoral pain syndrome is recognized as "runner's knee" and changes in activity pattens such as excessive increases in running milage, repetition, and the addition of strength exercises affect the patellofemoral joint. She indicated that the Veteran's complaints of left knee pain was during the time frame of entering active military service, and no complaints of knee pain were found upon enlistment with the Army National Guard. The next documented complaint regarding the left knee was in November 2012, which noted a diagnosis of left knee osteoarthritis and previous 2010 surgery with bone fragments removed from previous traumatic injury. The examiner concluded that the Veteran's left knee disability was less likely than not due to his complaints of knee pain during service, as patella femoral syndrome is not a causative factor for osteoarthritis. She further concluded that the Veteran's left knee disability was more likely than not related to his traumatic injury, elevated BMI, and natural progression of aging. The Board finds that remand for a supplemental VA medical opinion is warranted as the October 2015 VA examiner failed to adequately consider and address the Veteran's statements regarding onset and duration of symptoms and largely based her opinion on the absence of treatment post-service. Additionally, while the examiner attributes the Veteran's left knee disability to a traumatic injury, the record does not contain any record or description of this referenced traumatic injury. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, forward the claims file to a qualified medical professional to obtain a medical opinion regarding the nature and etiology of the Veteran's neck, back, right shoulder, and left knee disabilities. If the examiner determines that another physical examination is necessary, such an examination should be scheduled. Following a review of the claims file, the examiner is asked to opine as to the following: a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's neck disability occurred in or is otherwise etiologically related to active service, to include as due to the in-service pool incident? b) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's back disability occurred in or is otherwise etiologically related to active service or a period of ACDUTRA in May 1992? c) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's right shoulder disability occurred in or is otherwise etiologically related to a period of ACDUTRA in January 1991? d) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's left knee disability occurred in or is otherwise etiologically related to active service? The examiner is advised that the Veteran is competent to report symptoms, including continuity of symptoms and treatment, and the examiner must take into account, along with the other evidence of record, the Veteran's statements in formulating the requested opinions. Moreover, the examiner is advised that a lack of documentation on its own is not dispositive of the question. All opinions expressed should be accompanied by supporting rationale. Nathaniel J. Doan Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Robinson, 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.