Citation Nr: 21074269 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 16-62 031 DATE: December 14, 2021 REMANDED Entitlement to service connection for a bilateral shoulder disability is remanded. Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1977 to October 1980. The Department of Veterans Affairs (VA) is grateful for her service. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at the Board of Veterans' Appeals (Board) in September 2021. A transcript of the hearing is of record. 1. Entitlement to service connection for a bilateral shoulder disability is remanded. 2. Entitlement to service connection for a back disability is remanded. At her September 2021 hearing, the Veteran testified that her back disability began in service due to her lifting equipment when working in a medivac unit, that she was seen for her back problem in 1979, and that it persisted until her separation from service in 1980. She also testified that she then also injured her shoulders, and that her shoulder problems also continued until her service separation, though less so that her back problem. She testified to first seeking medical care for her back or shoulders in 2000, and prior to that time, though her conditions were persistent from service until she sought medical care, and though she sought medical care for other conditions during that interval, she only used self-care for her back and shoulders, which she reported included a heating pad, topical patch, or pain medication. She testified that she currently had arthritis of the back, though that developed later, and that she had rheumatoid arthritis. The Veteran was afforded a VA back examination in January 2015, and the examiner noted that while the Veteran had been seen in service for thoracic sprain/strain, that was a self-limited injury which "does not cause permanent pathology." The examiner, including on that basis, opined that the Veteran's current degenerative condition of the spine was not at least as likely as not (less than 50 percent probability) related to service, but rather was "due to her age and body habitus." The VA Regional Office (RO) did not afford the Veteran a VA examination in furtherance of her bilateral shoulder claim because RO did not find sufficient indication of a link to service to warrant an examination. The Board now finds that the Veteran's statements and testimony to the effect that her back and shoulder disabilities have been persistent following in-service injury are sufficient to warrant a new examination addressing the claimed back and shoulder disabilities, notwithstanding the 20-year interval following service during which she did not seek medical care for these problems. The January 2015 back examination opinion is inadequate for failure to consider competent evidence consisting of the Veteran's statements and testimony of symptoms of back disability persistent from service. A medical opinion is inadequate if it relies on an inaccurate factual basis. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). An examination for the shoulders is necessary based on the presence of current disability as supported by current treatment records, and evidence of an event in service and an indication of a link between such event and current disability as supported by the Veteran's testimony. 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i); see also McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The matters are REMANDED for the following actions: 1. Obtain any outstanding VA and pertinent private treatment records, with appropriate assistance and authorization from the Veteran. The Veteran and his representative should be notified of any records that cannot be obtained. 2. Thereafter, schedule the Veteran for an examination by a medical professional qualified to address the nature and etiology of shoulder and back disabilities. The claims file should be made available to and reviewed by the examiner in conjunction with the examination. Any necessary tests or studies should be obtained, and pertinent results should be reported in detail in the examination report. The examiner should be advised that the prior back examination in January 2015 was inadequate for failure to provide a rationale supporting its opinion which adequately considered the Veteran's self-reported history of back disability. The examiner must also document and consider the Veteran's own statements regarding her disability, since a layperson is competent to address symptoms as experienced and her recollections of past history and treatment. If the examiner has reason based on other evidence of record or medical knowledge to question the Veteran's self-reported history, the examiner should so state and provide a complete explanation why this is so. a. For any back disability present during the claim period, the examiner should provide an opinion addressing whether it is at least as likely as not (50 percent or greater probability) that the disability began in service or is otherwise causally related to service. The examiner must support this opinion with a rationale (explanation supported by evidence and medical knowledge) which considers the documentary evidence as well as the Veteran's lay statements of history, as provided at the examination, in written statements, and in her September 2021 hearing testimony. The examiner should specifically consider her self-reports of her history of symptoms, self-care, and care by medical professionals. b. For any shoulder disability present during the claim period, the examiner should provide an opinion addressing whether it is at least as likely as not (50 percent or greater probability) that the disability began in service or is otherwise causally related to service. The examiner must support this opinion with a rationale (explanation supported by evidence and medical knowledge) which considers the documentary evidence as well as the Veteran's lay statements of history, as provided at the examination, in written statements, and in her September 2021 hearing testimony. The examiner should specifically consider her self-reports of her history of symptoms, self-care, and care by medical professionals A complete rationale should be provided for each opinion. 3. Thereafter, readjudicate the appealed claims. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Schechter 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.