Citation Nr: 21073662 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 16-55 696 DATE: December 9, 2021 REMANDED Entitlement to service connection for a right shoulder condition, to include tear of infraspinatus tendon and AC joint degenerative changes is remanded. Entitlement to service connection for bilateral plantar fasciitis is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1979 to June 1986, and December 1990 to July 1991 with additional periods of service with the Army Reserves. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in September 2010 by a Department of Veterans Affairs (VA) Regional Office. In April 2017, the Veteran testified at a Board hearing before a Veterans Law Judge. A transcript of the hearing is associated with the record. In a November 2020 letter, the Veteran was informed that Veterans Law Judge is no longer with the Board, and that she may testify at a new Board hearing before a Veterans Law Judge. In a November 2020 letter, the Veteran declined the opportunity for an additional Board hearing. The above claims were remanded in January 2019 and February 2021 for additional development, along with the claim for entitlement to service connection for a left shoulder disability. While on remand, an August 2021 rating decision awarded service connection for a left shoulder disability, effective November 20, 2009. As such award constitutes a full grant of benefits sought on appeal, the claim is no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997); A.B. v. Brown, 6 Vet. App. 35 (1993). The remaining issues now return to the Board for further appellate review. 1. Entitlement to service connection for a right shoulder condition. The Veteran contends that she injured her right shoulder during training at Fort McCoy when she jumped off a Humvee with a duffle bag and fell on her shoulder. As noted in the February 2021 remand, the Veteran testified at the Board hearing that she could not remember the specific year the injury occurred and there are no service treatment records that corroborate the injury. However, in February 2010, two service-members submitted statements, stating that they witnessed the Veteran injuring her shoulder while taking her duffle bag off a military vehicle in the line of duty. In accordance with the February 2021 Board remand, the Veteran was afforded a VA examination in April 2021. At the time, the VA examiner found that the Veteran's right shoulder condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale, it was provided that the Veteran testified that her right shoulder pain started a few years after her service in Desert Storm. In 2001, she noted that she did not have any shoulder pain. The Veteran underwent an MRI for her right shoulder in 2007, at which time the Veteran reported that she had pain for a few months but did not suffer any trauma. Therefore, while the Veteran injured her shoulder due to a duffle bag incident, no nexus could be established. However, the Board finds the April 2021 opinion to be inadequate as the VA examiner primarily relied on the fact that the service treatment records are silent to any complaints or treatment or right shoulder disorder. The examiner also failed to discuss the Veteran's reports that she self-treated with muscle relaxers on the day of the injury, as instructed by the February 2021 remand directives. Moreover, the examiner did not address the two February 2010 statements by the Veteran's fellow service-members which describe the Veteran's injury to her right shoulder while in the line of duty. In this regard, the sole basis for rejecting lay statements cannot be the fact that there are no corroborating records. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("the Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In light of the foregoing, the Board finds a remand is necessary to obtain another addendum opinion which addresses the etiology of the Veteran's right shoulder disability. 2. Entitlement to service connection for bilateral plantar fasciitis. As noted in the February 2021 remand, the Veteran contends that her bilateral plantar fasciitis is caused by years of running and exercise during her active duty service. Specifically, at the April 2017 Board hearing, she testified that she first had problems during active duty service in 1983 while stationed in Germany and was put on profile to wear tennis shoes instead of boots. She also reported that she has had pain in her feet since her separation from service. Pursuant to the February 2021 remand directives, the Veteran was also afforded a VA examination in April 2021 for her bilateral plantar fasciitis. The examiner opined that the condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In this regard, the examiner noted that the Veteran was on active duty from 1979 to 1986 and 1990 to 1991. On the reports of medical history in 1990, 1991 and 2001, she noted "no" to foot trouble. As such, her current plantar fasciitis started after her time in service. However, the Board finds the April 2021 opinion to be inadequate as the examiner did not consider and discuss the Veteran's reports that she had foot pain in service, was put on profile to wear tennis shoes while in Germany, and has had pain since separation from service. Rather, the examiner improperly relied on the lack of in-service and post service treatment for a bilateral plantar fasciitis. Accordingly, the Board finds a remand is necessary to obtain an addendum opinion which address the Veteran's reports of in-service pain and continuity of symptomatology following separation from service. The matters are REMANDED for the following action: Return the record, to include a copy of this Remand, to the April 2021 VA examiner who provided the right shoulder and bilateral plantar fasciitis VA examinations. If the April 2021 VA examiner is not available, the record should be forwarded to an appropriate VA clinician for an addendum opinion addressing the etiology of the Veteran's claimed conditions. Following a full review of the record, the examiner should offer an opinion as to the following: (A) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's current right shoulder disorder, diagnosed as tear of infraspinatus tendon and AC joint degenerative changes, had its onset in, or is otherwise related to, her military service, to include her injury while falling on her shoulder off a Humvee. In offering such opinion, the examiner should consider and discuss the Veteran's statements that on the day of the injury, she pursued self-treatment for the injury, to include taking muscle relaxers. The examiner should also consider and discuss the February 2010 statements by the Veteran's fellow service-members, which state that they witnessed the Veteran injuring her right shoulder during the line of duty. (B) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's bilateral plantar fasciitis had its onset in, or is otherwise related to, her military service, to include years of running and exercising in service. In offering such opinion, the examiner should consider and discuss the Veteran's reports of pain in her feet since separation from service and being placed on profile to wear tennis shoes instead of boots while she was stationed in Germany in 1983. The examiner is advised that the sole basis of a negative opinion cannot be the fact that the Veteran's service treatment records are silent as to a right shoulder disability or bilateral plantar fasciitis, or any complaints thereof. The examiner is also advised that a lack of medical records demonstrating a continuity of care after service cannot form the sole basis of a negative opinion. A rationale for any opinion offered should be provided. J. DWORKIN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Waite 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.