Citation Nr: 21070913 Decision Date: 11/26/21 Archive Date: 11/26/21 DOCKET NO. 16-02 997 DATE: November 26, 2021 REMANDED Entitlement to service connection for mild intermittent right shoulder joint and right trapezius strain is remanded. Entitlement to service connection for left shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Marine Corps from March 2005 to March 2009. These matters come to the Board of Veterans' Appeals (Board) on appeal from July 2014 and February 2018 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). These claims were previously remanded by the Board in September 2018, June 2020, March 2021, and July 2021 for further development. The matters have since been returned to the Board for appellate consideration. 1. Entitlement to service connection for mild intermittent right shoulder joint and right trapezius strain is remanded. 2. Entitlement to service connection for left shoulder disability is remanded. This matter was last before the Board in July 2021 and the Board remanded the matter requesting an addendum opinion regarding the etiology of the Veteran's bilateral shoulder disabilities and whether it was at least as likely as not (50 percent or greater probability) that the Veteran's right and left shoulder disabilities are causally related to his military service. The Board requested the addendum opinion consider and address the lay statements made by the Veteran concerning the onset and continuity of his symptomatology, specifically that wearing flak jackets and rucksacks during service gradually resulted in shoulder pain, and the Veteran's contentions that he experienced this pain during service but did not report it or seek treatment for it. The Board directed if the examiner believed it is significant that the Veteran was not treated for these shoulder disabilities during his military service, the examiner must provide an explanation as to why it is significant. The Board further directed that if there were a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Finally, the Board directed that a full rationale must be provided for any opinion offered and that a thorough explanation would be helpful to the Board. An addendum medical opinion was obtained in August 2021. The opinion provides very little information, analysis, or rationale. Instead, the VA examiner concluded, "[a] review of Veteran's available medical records and remand letter does not provide any documentation indicating that the Veteran complained of, or was treated for shoulder pain during his military career. Hence it is less likely than not that the Veteran's right shoulder condition incurred in or was caused by the claimed in-service injury, event or illness." See, August 2021 C&P Exam. The Board finds the August 2021 addendum medical opinion inadequate for several reasons and the VA examiner failed to comply with the Board's July 2021 remand directives. Specifically, the VA examiner: 1) failed to address the etiology of the Veteran's bilateral shoulder disabilities; 2) failed to consider and address the lay statements made by the Veteran concerning the onset and continuity of his symptomatology, specifically that wearing flak jackets and rucksacks during service gradually resulted in shoulder pain, and that the Veteran experienced this pain during service, but did not report it or seek treatment for it; and 3) inadequately addressed the Veteran's right shoulder disability and failed to address and provide an opinion or rationale regarding the Veteran's left shoulder condition. See, August 2021 C&P Exam. As stated, the VA examiner's conclusion regarding the Veteran's right shoulder disability is inadequate. The conclusion is based solely on the absence of documentation in the Veteran's available medical records of an in-service injury or disability. A medical opinion based solely on the absence of documentation in the record is inadequate, and a medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history. See Dalton v. Peake, 21 Vet. App. 23 (2007). Since the August 2021 addendum medical opinion failed to minimally or adequately comply with the July 2021 Board remand directives, and the VA examiner based his decision on the absence of documentation of an injury or disability, the Board finds the August 2021 addendum medical opinion inadequate for adjudicative purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board must ensure compliance with the terms of its prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand confers on the veteran, as a matter of law, the right to compliance with the remand orders). As stated, the Board finds that there has not been substantial compliance with the directives of the July 2021 remand. Therefore, another remand is required in order to procure a medical opinion supported by a sound rationale before the Board can render a fully informed decision on the merits of the Veteran's appeal. The matter is REMANDED for the following action: 1. Obtain an opinion from another appropriate provider regarding the etiology of the Veteran's mild intermittent right shoulder joint and right trapezius strain and Veteran's left shoulder disability. The examiner must review the claim file, and the Veteran's contentions which must be documented in the report. 2. The examiner is asked to provide a response to the following: is the Veteran's mild intermittent right shoulder joint and right trapezius strain and the Veteran's left shoulder disability at least as likely as not related to the Veteran's military service, including the Veteran's contentions that that his bilateral shoulder disabilities began during his service as the result of wearing flak jackets with plate inserts for extended periods of time and performing long marches carrying large rucksacks. 3. In providing this opinion, if there is any medical reason to accept or reject the proposition that his bilateral shoulder disabilities had a gradual onset, i.e., that his bilateral shoulder disabilities began during his service as the result of wearing flak jackets with plate inserts for extended periods of time and performing long marches carrying large rucksacks, this should be noted. Stated another way, is the Veteran's contention that incidents of his active service, to include wearing flak jackets and rucksacks without documented complaints at separation from service and with subsequent manifestations of symptoms and diagnosis following discharge from service, align with how his bilateral shoulder disabilities are known to develop or are such contentions generally inconsistent with medical knowledge or implausible? Provide the complete rationale to support the opinions expressed. 4. If upon completion of the above action the claim remains denied, the matter must be returned to the Board after compliance with appellate procedure. JOHN R. DOOLITTLE, II Veterans Law Judge Board of Veterans' Appeals Doolittle, John R. 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.