Citation Nr: 21069466 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 20-08 417 DATE: November 18, 2021 REMANDED Entitlement to service connection for left shoulder impingement syndrome with rotator cuff tear, labral tear, and degenerative arthritis, to include as secondary to a service-connected right shoulder strain with arthritis, is remanded. Entitlement to service connection for left arm carpal tunnel syndrome, including as secondary to a left shoulder disability and/or a right shoulder disability, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from October 1960 until his retirement in August 1990. These matters come before the Board of Veterans' Appeals (Board) from an April 2018 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). These claims were previously remanded by the Board for additional development in September 2020 and in August 2021. 1. Entitlement to service connection for left shoulder impingement syndrome with rotator cuff tear, labral tear, and degenerative arthritis, to include as secondary to a service-connected right shoulder strain with arthritis, is remanded. VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). In February 2018, the Veteran filed a claim seeking service connection for a left shoulder disability secondary to his service-connected right shoulder disability. He also submitted a March 2019 statement asserting his left shoulder injury was incurred during his active service. Thus, entitlement to service connection for a left shoulder disability under the theory of direct service connection is also indicated. In March 2019, the Veteran reported he initially injured both shoulders in September 1982. He indicated that as the right shoulder injury was more severe, his subsequent treatment focused on the right shoulder. The service treatment records confirm a September 1982 right shoulder injury and numbness radiating to the right hand. In support of his claim that the left shoulder was injured at the same time, the Veteran submitted a copy of a September 1982 physical therapy consultation form documenting a left upper thoracic paraspinal strain and intermittent bilateral ulnar radiculopathy. The Veteran also recalled experiencing multiple left shoulder and arm injuries and soreness over his years of active service. The injures occurred as he performed military police duties, including making physically strenuous arrests, patrolling dark areas, and working with sentry dogs (including participating in attack training.) He remembered sometimes seeking medical care and sometimes treating injuries on his own. The Veteran is competent to report his experience of injuries and his medical history of seeking treatment or using selfcare. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In May 2021, a VA examiner opined a left shoulder disability was less likely than not directly related to active service because the service treatment records documented only a right shoulder injury and no chronic shoulder condition was noted on the Veteran's separation examination. The examiner did not discuss the Veteran's March 2019 report of left shoulder and arm injuries or the September 1982 physical therapy consult records of bilateral ulnar radiculopathy. This opinion is not based on a complete review of the Veteran's medical history and it is inadequate to evaluate the issue of direct service connection. A new opinion must be obtained. See Stefl, supra. In August 2021, the Board found a May 2021 etiology opinion addressing whether a left shoulder disability was secondary to the service-connected right shoulder disability was incomplete and inadequate. In September 2021, a VA shoulder conditions examination was provided. The examiner diagnosed left shoulder impingement syndrome with rotator cuff tear, labral tear, and degenerative arthritis, status post left shoulder surgery. She opined the left shoulder condition was less likely than not proximately due to a service-connected right shoulder disability. She attributed the left shoulder injury to degenerative changes over time because the Veteran underwent left shoulder surgery 25 years after his military service. She also opined the left shoulder disability was less likely than not aggravated by the service-connected right shoulder injury because his left shoulder injury had not progressed "beyond aging and the normal sequela associated with degenerative changes." The examiner did not discuss the nature of the Veteran's right shoulder condition, including any possible right shoulder weakness and increased strain on the left shoulder over the years. Thus, the examiner did not sufficiently evaluate the Veteran's condition or his medical history. Her opinion is inadequate to evaluate the issue of secondary service connection. Id. No opinion as to direct service connection was provided in September 2021. There are no adequate opinions of record to evaluate whether the Veteran's left shoulder condition is directly related to his active service or secondary to his service-connected right shoulder condition. The claim must be remanded so that adequate etiology opinions can be obtained. 2. Entitlement to service connection for left arm carpal tunnel syndrome, including as secondary to a left shoulder disability and/or a right shoulder disability, is remanded. In February 2018, the Veteran filed a claim seeking service connection for left carpal tunnel syndrome secondary to left shoulder condition. As noted above, a September 1982 physical therapy consultation record documents in-service bilateral ulnar radiculopathy. The Veteran's March 2019 statement indicates he experienced left arm injuries during his active service. Entitlement to service connection under the theory of direct service connection is also indicated. In May 2021, a VA examiner opined left carpal tunnel syndrome was less likely than not caused by his active service because there was no record of carpal tunnel symptoms or diagnosis during the Veteran's active service. The examiner did not discuss the Veteran's March 2019 report of left arm injuries or the September 1982 physical therapy consult records of bilateral ulnar radiculopathy. This opinion is not based on a complete review of the Veteran's medical history and it is inadequate to evaluate the issue of direct service connection. A new opinion must be obtained. Id. In August 2021, the Board found a May 2021 etiology opinion, which evaluated whether left carpal tunnel syndrome was secondary to the service-connected right shoulder disability, was incomplete and inadequate. In September 2021, a VA examiner opined left carpal tunnel was less likely than not proximately due to or aggravated beyond its natural progression by a right shoulder condition because the conditions were unrelated. The examiner did not explain whether any weakness of the right shoulder would increase strain on the left arm. Accordingly, the opinion is not based on a complete evaluation of the Veteran's medical history. It is inadequate to evaluate the claim. Id. There are no adequate opinions of record to evaluated whether the left shoulder condition is directly related to the Veteran's active service or secondary to his service-connected right shoulder condition. The claim must be remanded so that adequate etiology opinions can be obtained. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's left shoulder disability is at least as likely as not related to a September 1982 injury (as indicated in a September 1982 physical therapy consultation record) or to other left shoulder and arm injuries as reported in the Veteran's March 2019 statement. The clinician is advised that the Veteran is competent to report his experience of injury and of seeking treatment or using selfcare. If he or she dismisses any such reports from the Veteran, a complete rationale for doing so must be provided. The clinician may not dismiss the Veteran's report of symptoms capable of lay observation solely because they are not documented in contemporaneous medical records. The clinician must also opine whether the left shoulder disability is at least as likely as not proximately due to a service-connected right shoulder disability or aggravated beyond its natural progression by a service-connected right shoulder disability. The examiner must fully describe the nature of the right shoulder disability and any additional strain placed on the left shoulder by this condition. The clinician is advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. A complete rationale in support of each opinion must be provided. If the clinician determines an additional examination is required to provide the requested opinions, schedule an examination. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's left carpel tunnel syndrome is at least as likely as not related to a September 1982 injury (as documented in a September 1982 physical therapy consultation record) or to other left shoulder and arm injuries as reported in the Veteran's March 2019 statement. The clinician is advised that the Veteran is competent to report his experience of injury and of seeking treatment or using selfcare. If he or she dismisses any such reports from the Veteran, a complete rationale for doing so must be provided. The clinician may not dismiss the Veteran's report of symptoms capable of lay observation solely because they are not documented in contemporaneous treatment records. The clinician must also opine whether the left carpal tunnel syndrome is at least as likely as not proximately due to a service-connected right shoulder disability or aggravated beyond its natural progression by a service-connected right shoulder disability. The examiner must fully describe the nature of the right shoulder disability and any additional strain placed on the left arm by this condition. The clinician is advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. If a positive etiology opinion for a left shoulder disability is provided, the clinician must also opine whether the left carpal tunnel syndrome is at least as likely as not proximately due to the left shoulder disability or aggravated beyond its natural progression the left shoulder disability. The examiner must fully describe the nature of the left shoulder disability and any additional strain placed on the left arm by this condition. The clinician is advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation A complete rationale in support of each opinion must be provided. If the clinician determines an additional examination is required to provide the requested opinions, schedule an examination. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeanne Celtnieks 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.