Citation Nr: 21066369 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 11-19 695 DATE: October 29, 2021 REMANDED Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a lower back disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 2001 to August 2005 and from May 2006 to September 2007. For his meritorious service, the Veteran was awarded (among other decorations) the Army Commendation Medal and the Iraq Campaign Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the Veteran testified at a video conference hearing held before the undersigned Veterans Law Judge. A transcript of this hearing has been added to the record. In March 2019 and 2021, the Board remanded this matter for additional evidentiary development. 1. Entitlement to service connection for a right shoulder disability is remanded. 2. Entitlement to service connection for a lower back disability is remanded. The Veteran is seeking service connection for right shoulder and low back disabilities. The Veteran contends that his right shoulder disability and low back disability are related to his active service, to include in-service reports of back pain and a tear of the right rotator cuff. To that end, the Veteran was afforded the May 2021 VA examinations to determine the nature and etiology of his claimed disabilities. The VA examiner diagnosed the Veteran with strains of the lumbar spine and right shoulder. The VA examiner found the Veteran's current disabilities of the lumbar spine and right shoulder to be unrelated to his active service. The VA examiner provided that muscle strains are often self-limiting and occur in the general medical population, and without medical evidence of continuity and chronicity of care from the time the Veteran sustained his injuries in service. The VA examiner, however, did not address the connection, if any, between the Veteran's current right shoulder disability and his in-service right rotator cuff injury nor did the VA examiner address the relationship, if any, between the Veteran's in-service reports of back pain and his current back disability. As such, further medical guidance is needed to address the etiology of the Veteran's claimed disabilities considering his in-service reports and injuries. The matters are REMANDED for the following action: Obtain an opinion as to whether the Veteran's right shoulder and low back disabilities are related to his active service. Whether an examination is needed prior to rendering this opinion is left to the discretion of the examiner. Regardless of whether an examination is performed, the examiner is to state: (a) Whether it is at least as likely as not that the Veteran's current right shoulder disability is related to his active service, to include in-service tear of the right rotator cuff. (b) Whether it is at least as likely as not that the Veteran's current low back disability is related to his active service, to include in-service reports of back pain and his service with postal operations. A rationale for all opinions expressed should be provided. The examiner should address the Veteran's reports of specific back and right shoulder trauma in service, as well as the service treatment records detailing specific injuries and treatment for his claimed conditions Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.R. Higgins 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.