Citation Nr: 21064971 Decision Date: 10/22/21 Archive Date: 10/22/21 DOCKET NO. 16-47 678 DATE: October 22, 2021 REMANDED Entitlement to service connection for a spine disability, to include a cervical spine and a thoracolumbar spine disability, originally claimed as a low back injury, is remanded. Entitlement to service connection for a left shoulder disability, to include as secondary to a spine disability, originally claimed as a left shoulder injury, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1984 to November 1987. This matter comes before the Board of Veteran's Appeals (Board) from a July 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in November 2019 and September 2020 when the claims were remanded for development. For the reasons explained below, the Board finds the matters must be remanded again. Procedural history By way of history, the Veteran presented a claim of service connection for a left shoulder injury and a low back injury in May 2013. Those claims were denied in a July 2014 rating decision. In his notice of disagreement (NOD), the Veteran asserted that while in service, he had fallen off a vehicle during a field training exercise which resulted in left shoulder and low back pain. See NOD. An August 2016 Statement of the Case (SOC) continued the denial of the claims and in September 2016, the Veteran perfected his appeal to the Board by presenting a completed Form 9. In September 2019, the Veteran provided testimony before the undersigned pertaining to his claims of service connection for a left shoulder and a back condition. The hearing transcript has been associated with the claims file. In November 2019, the Board remanded the claims for development. In pertinent part, the Board remanded the Veteran's claim for a back disability characterized as "entitlement to service connection for a cervical spine disability." While the Board did not explicitly note that it was recharacterizing the claim, the remand noted that the Veteran's medical records showed ongoing treatment for back pain and a diagnosis of degenerative disc disease of the cervical spine. Based on the Veteran's cervical spine diagnosis noted in the medical records, the Board remanded the claim of a back disability to obtain an examination and medical opinion on the likelihood of an etiological relationship between the Veteran's claimed in-service incurrence and his "spine disability" pursuant to McLendon v. Nicholson, 20 Vet. App. 79 (2006). Thus, implicitly, the Board found that the scope of the Veteran's claim for a back injury could reasonably encompass the diagnosed spine disability as shown in the medical records, and remanded the matter for a VA examination pertaining to the spine. In February 2020, the Veteran was administered a Neck (Cervical Spine) Conditions Disability Benefits Questionnaire (Neck DBQ) and a medical opinion was obtained pertaining to the likely etiology of the condition. In September 2020, the Board remanded the claim again, characterized as "entitlement to service connection for a cervical spine disability, to include degenerative disc disease of the cervical spine" for addendum opinions which were provided in October 2020 and December 2020. The matters are again before the Board. The scope of the claims When reviewing an application for benefits, the Board must give it "a sympathetic reading" so as to "determine all claims for recovery supported by a liberal construction." Szemraj v. Principi, 357 F.3d 1370, 1376 (Fed. Cir. 2004). A sympathetic reading of a claim includes a duty to apply some level of expertise in reading documents to recognize the existence of possible claims that an unsophisticated claimant would not be expected to be able to articulate clearly. See Ingram v. Nicholson, 21 Vet. App. 232, 255 (2007). Additionally, although an appellant who has no special medical expertise may testify as to the symptoms he can observe, he generally is not competent to provide a diagnosis that requires the application of medical expertise to the facts presented, which includes the claimant's description of history and symptomatology. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence of laypersons to testify as to symptoms but not medical diagnosis and noting example in n.4 of competence of lay testimony with regard to a broken leg but not a form of cancer). Further, the scope of a claim is generally not limited necessarily to the specific diagnosis or condition claimed. Rather, the Secretary (VA) must investigate the reasonably apparent and potential causes of the veteran's condition and theories of service connection that are reasonably raised by the record or raised by a sympathetic reading of the claimant's filing. See Schroeder v. West, 212 F.3d 1265, 1271 (Fed. Cir. 2000); Robinson, 21 Vet. App. at 552 (characterizing Schroeder as holding that "the duty to assist applies to the entire claim, which might require assistance in developing more than one theory in support of that claim"); see also Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001); Brokowski, 23 Vet. App. at 85. Overall, the scope of the claim will be based on a sympathetic assessment of "the claimant's description of the claim; the symptoms the claimant describes; and the information the claimant submits or that the Secretary obtains in support of the claim," i.e., the information gathered upon investigation. See Delisio v. Shinseki, 25 Vet. App. 45 (2011) (citing Clemons, 23 Vet. App. at 5). Moreover, the duty to fully and sympathetically develop a veteran's claim includes resolving any pleading ambiguities in favor of the veteran. Harris v. Shinseki, 704 F.3d 946, at 949 (2013) (discussing the duty to fully develop any filing made by a pro se veteran when determining whether an informal claim has been filed). In the present appeal, the Veteran presented claims of service connection for an injury to the left shoulder and a lower back injury. See VA 21-526 of May 2013. In his notice of disagreement (NOD), the Veteran explained that his claimed left shoulder and lower back injuries happened in a training accident while in service, where he slipped and fell off the back of a vehicle. He explained that he did not seek treatment at the time because he was beginning his "out-processing," but asserted he was feeling pain in his left shoulder and lower back prior to his separation from service. He noted he has dealt with his pain over the years, struggles to use his left shoulder, and has severe low back pain. See NOD. At the hearing in September 2019, the Veteran explained he had been treated for his shoulder and back pain and that he had received therapy following service. Additionally, the Veteran reported that his doctors had noticed bone spurs and herniated discs in his neck. See hearing transcript, page 11. The evidence of record includes medical treatment and therapy for a cervical spine condition. See generally medical records of 2006. Thus, as it can be ascertained from the procedural history, the Board in its previous remands recharacterized the Veteran's claim of service connection for a low back injury, to include the cervical degenerative disc disease diagnosis, in view of its duty to sympathetically read the evidence of record, and in further view of the Veteran's testimony at the hearing. However, while the characterization of the Veteran's claims has varied in the Board's previous remands, the characterization of the claims by the Board cannot serve to somehow limit the scope of the Veteran's claim to just include the diagnosed cervical disability and implicitly exclude the Veteran's claimed low back injury/pain. Accordingly, the Board has again recharacterized the Veteran's claim of service connection as "entitlement to service connection for a spine disability, to include a cervical spine disability and a thoracolumbar spine disability" to dispel any confusion that may have arisen from the Board's previous characterizations of the claim. Additionally, as it will be explained in more detail below, the claim of service connection for a left shoulder injury, has been further recharacterized in this decision in view of the evidence of record. 1. Entitlement to service connection for a spine disability, to include a cervical spine and a thoracolumbar spine disability, originally claimed as a low back injury, is remanded. Where VA provides a veteran with an examination or obtains a medical opinion in a service connection claim, the examination and or opinion obtained must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Here, in February 2020, the Veteran was administered a Neck (Cervical Spine) Conditions Disability Benefits Questionnaire (Neck DBQ); pursuant to the Board's November 2019 remand that requested an examination for the Veteran's spine disability. This Neck DBQ noted diagnoses of "herniated disc" and radiculopathy of the left upper extremity. As to the medical history of the condition, the Veteran reported he had started having problems with his neck after his fall in service and described numbness and tingling in the fingertips of left hand and arm. The examiner noted an abnormal range of motion for the neck (cervical spine) and noted findings of radiculopathy in the left upper extremity. See Neck DBQ of February 2020. This Neck DBQ did not cover any low back conditions or complaints. Following the examination, the examiner opined that the claimed condition was less likely than not incurred in or caused by service. In favor of this opinion, the examiner noted the Veteran's report of an in-service fall but determined that the medical records available did not show chronicity or continuity of symptoms. See medical opinion of February 2020. In September 2020, the Board found the February 2020 medical opinion inadequate for adjudication purposes, as the examiner did not provide a clear rationale for the opinion expressed. Thus, the Board remanded the matter again for medical opinions addressing the Veteran's conditions. To the extent that medical opinions were obtained pursuant to the Board's remand, the Board finds the remand directives of September 2020 were substantially complied with. Stegall v. West, 11 Vet. App. 268, 271 (1998). In October 2020, a medical opinion addressing the likely etiology of the neck condition noted that there was no separation exam of record, that there was no record of the Veteran's in-service fall and that lay statements submitted by the Veteran in favor of his claim for a low back disability did not mention or reference a neck condition. The examiner also noted the medical evidence of record, to include an MRI of 2006 showing a diagnosis of bulging disc at C5-6, the Veteran's motor vehicle accident of 2017, and referenced the other documents of record, to include the NOD. Based on the documentation noted, the examiner opined that the Veteran's cervical spine condition was less likely than not related to service because there was no documented neck injury while in service and the statements in support of the Veteran's claim, then characterized as low back, did not include anything pertaining to a neck injury or neck pain. The examiner further noted that the Veteran's disability claims "did not include a cervical spine condition until after" the vehicle accident of 2017. See medical opinion of October 2020. It is noted that in November 2019, the Board recharacterized the Veteran's claim of a back disability to include his diagnosed cervical condition in view of his testimony at the hearing and in view of the medical records showing a diagnosis pertaining to the cervical spine. In December 2020, another medical opinion addressing the likely etiology of the cervical condition was associated with the claims file. This medical opinion noted that degenerative disc disease is an age-related condition that happens when one or more of the discs between the vertebrae of the spinal column deteriorate or break down, leading to pain. It also noted that a herniated disk, or a bulged, slipped, or ruptured disc occurs when the fragment of the disc nucleus is pushed out of the annulus into the spinal canal through a tear or rupture in the annulus. Possible causes of herniated discs were noted as "excessive strain or injury" and the natural processes of ageing. The examiner noted the Veteran's report of an in-service injury for which he did not seek treatment, and that the medical treatment records did not note treatment or diagnoses of a cervical spine condition during service or a neck injury. Thus, the examiner opined that a nexus had not been established. See medical opinion of December 2020. The Board finds the October 2020 and December 2020 medical opinions inadequate for adjudication purposes. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Both opinions rely heavily on the absence of contemporaneous medical evidence to substantiate the negative opinions provided as they both note that the Veteran's service treatment records (STRs) do not show treatment, complaints or diagnosis of a cervical spine disability and determine based on such absence that the condition is less likely as not related to service. See Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006). However, neither examiner opined on the Veteran's competent report of continuous neck pain since service, following his claimed in-service injury, as noted in the Neck DBQ of February 2020 and in the available medical records in the claims file. Additionally, as to the medical opinion of December 2020, the Board notes that the language of "a nexus has not been established," in the rationale, is problematic as it is framed in absolute terms rather than the "at least as likely as not" standard. It is noted that saying that "a nexus has not been established" is not the same as saying that there likely is no nexus. Accordingly, the matter must be remanded for a new medical opinion that addresses the Veteran's competent report of pain since service, and his related symptomatology. Additionally, the Board notes that while the Veteran was administered a VA examination for his neck (cervical spine), he has not been provided an examination regarding his lower back (thoracolumbar spine). Thus, in order to ensure that VA's duty to assist the Veteran in the development of his claim has been fulfilled; the Board finds that new examinations for his spine, cervical and lumbar (low back) spine must be completed, and medical opinions addressing each spinal area (cervical, lumbar) must be associated with the claims file. The Board is specifically requesting that the whole spine be examined by the same examiner, to allow for the examiner to have a complete record upon which to base his or her medical opinions addressing separately the Veteran's cervical spine and his low back (thoracolumbar spine). The Board observes that the records do not seem to show a specific diagnosis pertaining to the lumbar spine. However, pertinent to the present case, in Saunders v. Wilkie, 886 F.3d 1356 (2018), the Federal Circuit found that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability." In other words, where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. Here, the Veteran has competently reported low back pain that has persisted since service. While the Board indeed expanded the scope of his back claim, based on the evidence of record, to include a cervical spine disability as explained above, the Board did not limit the scope of the Veteran's claim to just the cervical condition that had been diagnosed. The Veteran has asserted that he has experienced continued back pain since his claimed in-service fall. See NOD and hearing transcript. Thus, pursuant to Saunders and the duty to assist, a medical examination for the low back must be completed and a medical opinion on the likely etiology of the condition or functional limitation, if any, must be obtained. The examiner is asked to obtain from the Veteran a description and history of his low back pain symptomatology and must opine whether the Veteran's low back pain is a separate condition or at least as likely as not a manifestation of his diagnosed cervical spine disability, and provide an opinion on the likely etiology of the condition or functional limitation if any, to include whether it is at least as likely as not related to the Veteran's claimed in-service fall. Additionally, the Board clarifies that while indeed, the Veteran's medical records show that he was involved in a vehicle accident in 2017, his claim for a low back injury and his assertions regarding pain pre-date such event. See generally NOD, statements of record and hearing transcript. Similarly, the Veteran's cervical spine diagnosis of a bulging disc or degenerative disc disease also pre-date the vehicle accident of 2017. See generally medical records for 2006 and VA medical records for 2015. Thus, while the accident of 2017 could be relevant to the examiner's analysis, the medical opinions obtained should be based on an analysis of the complete medical evidence of record and the Veteran's competent statements regarding his symptomatology. See generally, Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012). Finally, it is acknowledged that the Veteran is competent to report symptomatology as he has perceived it through his senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The absence of contemporaneous medical evidence confirming or supporting the Veteran's lay assertions cannot be used, on its own, to support a negative nexus opinion. In other words, the lack of contemporaneous medical evidence alone is insufficient rationale for a negative nexus opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2010); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). Thus, in rendering the requested opinions addressing separately the Veteran's cervical spine and thoracolumbar spine, the examiner must consider the Veteran's competent statements regarding his pain onset and continuity. 2. Entitlement to service connection for a left shoulder disability, to include as secondary to a spine disability, originally claimed as a left shoulder injury, is remanded. The Veteran seeks service connection for a left shoulder injury. For the reasons explained below, the matter has been recharacterized as it appears on the title page of this decision and must be remanded for development, to include a new examination and medical opinion. In February 2020, the Veteran was administered a Shoulder and Arm Conditions Disability Benefits Questionnaire (Shoulder DBQ) where the examiner noted that the Veteran did not have a current diagnosis pertaining to his left shoulder, although the Veteran had an abnormal range of motion. The examiner found that pain was noted in the exam but did not contribute to functional loss. The examiner further noted that the Veteran's pain and decreased of range of motion was due to radiculopathy. It is noted that the examination report shows that a left shoulder rotator cuff condition was suspected as the Veteran was unable to perform the pertinent tests. No explanation as to the Veteran's inability to perform the tests was noted in the pertinent section for rotator cuff conditions. Nonetheless, in the remarks section of the report, the examiner noted that all objective evidence found on exam was due to the radiculopathy diagnosed and that there was no objective evidence of any additional left shoulder condition. See Shoulder DBQ of February 2020. Following the examination, the examiner opined that the diagnosed radiculopathy condition was less likely than not related to the Veteran's claimed condition of a left shoulder disability. The examiner then addressed radiculopathy along the cervical condition and provided a negative opinion based on a lack of chronicity or continuity noted in the medical records. See medical opinion of February 2020. In September 2020, the Board found this medical opinion inadequate for adjudication purposes and remanded the matter for a new medical opinion. To the extent that medical opinions were obtained pursuant to the Board's remand, the Board finds the remand directives of September 2020 were substantially complied with. Stegall v. West, 11 Vet. App. 268, 271 (1998). In October 2020, a medical opinion was associated with the claims file addressing both the cervical condition and the left shoulder condition. Pertinent to the left shoulder condition, this opinion noted that the medical records showed an old clavicle fracture in 2015. The examiner opined that the Veteran's left shoulder condition, distal clavicle fracture, was less likely than not incurred while in service as there was no documented left shoulder injury while in service nor any record of being placed on profile nor light duty due to a shoulder injury. The examiner further noted that breaking a clavicle is extremely painful and results in an acute disability which would have affected the Veteran to such an extent that the injury could not have been ignored while on active duty. See medical opinion on direct service connection of October 2020. The opinion on direct service connection of October 2020 is found inadequate in view of its internal inconsistencies and due to its heavy reliance on the absence of contemporaneous medical records showing treatment for the condition to support a negative nexus. As to the internal inconsistency, the examiner noted a condition of a clavicle fracture based on medical records of 2015 and supported his negative opinion based on speculated symptomatology of a broken clavicle (an injury that could not be ignored) as opposed to a fractured one. Thus, as the examiner did not reconcile the inconsistencies, mainly how symptomatology associated with a broken clavicle would be the same as the symptomatology associated with a fractured clavicle, the opinion is inadequate. Further, as the examiner heavily relied on the absence of contemporaneous evidence documenting the Veteran's fall and discarded without any reasoned explanation the Veteran's competent statements regarding an in-service fall and his pain since then, the opinion is inadequate. Further, as the examiner did not address the medical records of 2015 noting the Veteran's clavicle fracture and his reports of left shoulder/clavicle pain since his claimed in-service fall, the opinion is incomplete. Additionally, the examiner opined that the Veteran has left upper extremity radiculopathy, a nerve condition, secondary to his cervical spine condition. The examiner noted that the Veteran's radicular symptoms did not occur until his motor vehicle accident and thus the examiner opined that the radiculopathy was less likely than not due to a possible cervical spine condition or accident while in service but rather was caused by the motor vehicle accident. See medical opinion of October 2020 for direct service connection and for secondary service connection. The Board notes that this opinion on secondary service connection is inadequate and contradicts medical evidence of record showing that the Veteran's cervical disability manifested with radiculopathy prior to his accident. See medical records for 2006. However, as the Veteran is not currently service-connected for a cervical spine condition, development by the Board to correct the deficiency would be premature, at this juncture. In December 2020 two medical opinions addressing the left shoulder were associated with the claims file. One, regarding direct service connection, explained that medical records for June 2015 noted "old clavicle fracture, refer to orthopedist" and a note of "shoulder impingement syndrome," but that the STRs did not show treatment or diagnoses for a left shoulder condition, including a clavicle fracture or shoulder impingement syndrome. The examiner further noted that shoulder impingement syndrome is an injury to the muscles between the bones in the shoulder, due to overuse or repeated use of the shoulder and that a clavicle fracture is a fracture of the clavicle or the collar bone, often caused by a direct blow to the shoulder, such as a fall on the shoulder or a motor vehicle accident. Thus, the examiner concluded that "a nexus has not been established." See medical opinion of December 2020 on direct service connection. The Board finds this medical opinion is inadequate as it conclusory in nature and is mainly based on the absence of contemporaneous medical records documenting the Veteran's in-service fall or a shoulder condition to provide a negative opinion, without addressing the Veteran's competent report of continuous left shoulder pain since his fall in service or the other medical evidence of record. Horn v. Shinseki, 25 Vet. App. 231, 234 (2012); see also Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2010); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). Additionally, the Board notes the language used by the examiner in this opinion is problematic as it is framed in absolute terms "a nexus has not been established" rather than the "at least as likely as not" standard. It is noted that saying that "a nexus has not been established" is not the same as saying that there likely is no nexus. The examiner also noted, in the section of the opinion regarding conflicting medical evidence of December 2020, that the Veteran had a diagnosis of left upper extremity radiculopathy which is not considered an actual shoulder condition. See medical opinion of December 2020 regarding conflicting medical evidence. The second opinion associated with the claims file in December 2020, was a medical opinion for secondary service connection where the examiner explained that the Veteran has radiculopathy of the left upper extremity, as evidenced in the medical records from July 2016 noting degenerative disc disease of the cervical spine with radiculopathy. Thus, the examiner opined that a "nexus has been established for upper extremity radiculopathy due to or the result of cervical DDD [degenerative disc disease]." Thus, as it can be ascertained from the above, there is no adequate medical opinion of record addressing whether the Veteran has a current left shoulder condition, other than radiculopathy, and whether such left shoulder condition is at least as likely as not etiologically related to his claimed in-service fall. Additionally, as correctly noted in the October 2020 and the December 2020 medical opinions, the Veteran's medical records of June 2015 show that the Veteran was seen for an orthopedic consult for left shoulder complaints. The history of the condition was noted as follows "left shoulder pain since the 80s while in military. Now with level 8 pain. Has pain in subacromial area and history of distal clavicle fx [fracture]. Pain increased with lifting. Sometimes sleeping on left side increases pain." The physical exam revealed full range of motion, with a positive finding on impingement testing. Imaging assessment was noted as "old nonunion distal clavicle" and a diagnosis of "impingement syndrome" was noted. See medical records for June 2015. Medical records for April 2015 show the Veteran reported neck issues from a fall suffered while in service and that since the fall he had a "knot" on the left clavicle which was still painful. Due to these complaints, the Veteran was administered an x-ray that revealed a nonunion of his distal clavicle fracture and that resulted in the orthopedic consult of June 2015 for left shoulder complaints. See VA medical records for April 2015 through June 2015. The Board notes that the Veteran's claim of service connection for a left shoulder injury was presented in May 2013, and in view of the medical evidence of record, his distal clavicle fracture and impingement syndrome diagnoses seem to be associated with his claim for a left shoulder injury. Thus, the Shoulder DBQ of February 2020 has been rendered inadequate, as it notes no pertinent diagnoses to the left shoulder and does not reconcile the distal clavicle fracture or impingement syndrome diagnoses, found in the medical records, with that finding. Further, while medical opinions have addressed these diagnoses, the medical opinions have been found inadequate for adjudication purposes as they are mainly based on a lack of contemporaneous medical evidence showing treatment for the conditions while in service, without addressing the Veteran's lay statements of an in-service fall and his complaints of continued pain. Accordingly, the Board finds the matter of entitlement to service connection for a left shoulder disability must be remanded for an examination to determine the Veteran's current left shoulder diagnoses, other than the radiculopathy diagnosis, and a medical opinion addressing the diagnoses and their likely etiology. The matters are REMANDED for the following actions: 1. Update existing VA medical records. 2. Schedule the Veteran for examinations pertaining to his cervical and thoracolumbar spine. Examinations pertaining to both the cervical spine and the thoracolumbar spine must be completed preferably by the same examiner and a history of the symptomatology the Veteran has experienced must be obtained from him, to include the symptomatology he has experienced pertinent to the cervical and the thoracolumbar spine, and any necessary clarifications as to his pain and the location of such pain. Following the examinations of the complete spine, to include the completion of any necessary diagnostic testing, the examiner is asked to opine: Pertaining to the cervical spine: a. Is the Veteran's cervical spine disability at least as likely as not related to his in-service fall. In rendering this opinion, the examiner is asked to consider the Veteran's statements and his reported medical history, to include the medical records showing diagnoses pertaining to his cervical spine as early as 2006. The examiner is respectfully reminded that the lack of contemporaneous medical evidence alone is insufficient rationale to support negative nexus opinions and that the Veteran is competent to report symptomatology he has experienced. Pertaining to the thoracolumbar spine: b. Does the Veteran have a condition, disability, or diagnosis, affecting the thoracolumbar spine area? c. If no diagnosis pertaining to the Veteran's thoracolumbar spine area can be rendered the examiner is asked to clarify: i. whether the Veteran's low back pain is a symptom of his diagnosed cervical spine disability or whether it is a separate condition. ii. If the Veteran's low back pain is found to be separate from the cervical spine disability and no specific diagnosis for the low back pain can be rendered, the examiner is asked to opine whether the Veteran's low back pain results in functional impairment pursuant to Saunders v. Wilkie, 886 F.3d 1356 (2018). d. If there is a diagnosed disorder, disease, condition, disability, affecting the thoracolumbar spine OR functional limitations due to pain of the thoracolumbar spine, the examiner must opine as to whether the disability or functional limitation is at least as likely as not (50 percent likelihood or greater) related to the Veteran's claimed in-service fall. If deemed necessary by the examiner, diagnostic testing should be completed. In rendering the above requested opinions, the examiner is respectfully reminded that the Veteran is competent to report his symptomatology and that the lack of contemporaneous medical evidence is not sufficient rationale to support a negative opinion. 3. Schedule the Veteran for an examination pertaining to his left shoulder injury or disability. A medical history pertaining to the Veteran's left shoulder, to include the symptomatology he has experienced and any necessary clarifications as to his pain and the location of such pain must be obtained from the Veteran. Following the examination, the examiner is asked to: a. Clarify whether the Veteran has a left shoulder disability, other than the noted radiculopathy. i. The examiner is asked to expressly address the Veteran's clavicle fracture and shoulder impingement diagnoses as noted in the medical records for 2015. b. For each diagnosed condition (to include if diagnosed, clavicle fracture, shoulder impingement and radiculopathy), the examiner is asked to opine whether the condition is at least as likely as not related to his in-service fall. In rendering the above requested opinions, the examiner is respectfully reminded that the Veteran is competent to report his symptomatology and that the lack of contemporaneous medical evidence is not sufficient rationale to support a negative opinion. (Continued on the next page) The examiner is asked to provide a complete rationale for all opinions expressed. If the examiner cannot provide the requested opinion(s) without resorting to speculation, the report should expressly indicate this, and the examiner should explain why an opinion cannot be provided without resorting to speculation. If the inability to provide an opinion is the result of a need for additional information, the physician must identify the additional information needed. 4. After completing the above requested actions, and any additional notification and/or development deemed warranted, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, furnish to the Veteran and his representative an appropriate supplemental statement of the case that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Gonzalez-Maldonado 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.