Citation Nr: 21074369
Decision Date: 12/15/21	Archive Date: 12/15/21

DOCKET NO. 17-39 706
DATE: December 15, 2021

ORDER

Entitlement to service connection for a left shoulder disability, diagnosed as a left shoulder sprain, is granted.

FINDING OF FACT

Resolving all reasonable doubt in his favor, the Veteran's left shoulder sprain is causally related to his military service.

CONCLUSION OF LAW

The criteria for service connection for a left shoulder disability, diagnosed as a left shoulder sprain, have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. § 3.303 (2020).

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active naval service from November 2012 to November 2016.

This matter comes to the Board of Veterans' Appeals (Board) on appeal from April 2017 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO).

1.  Entitlement to service connection for a left shoulder disability

Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303 (b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d).

In order to establish service connection for the claimed disorder, there must be competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006).

Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

Analysis

The Veteran has contended that he incurred a left shoulder disability during active duty. Specifically, the Veteran reported that he injured his left and right shoulders on one occasion, falling through a scuttle while stationed aboard a naval ship. The Veteran further contends that he has continuing left shoulder problems after service. 

The Veteran's service treatment records (STRs) are silent as to complaints or reports of a left shoulder disability or symptoms congruent with such; however, the Veteran indicated 'Yes' to having a painful shoulder on the July 2016 separation examination report.

In October 2016, the Veteran filed a claim for service connection for joint pain in his bilateral shoulders, which was prior to separation from active naval service. 

An April 2017 primary care note shows that the Veteran's service-related shoulder pain was aggravated when working overhead and lifting heavy weights. Upon examination, the Veteran was positive for bilateral shoulder pain with crepitus. A May 2018 primary care note indicated that the Veteran was still having continuing shoulder problems after service. The Veteran stated that he feels like he has feeling of "persistent popping and instability."

At the April 2017 VA examination, the Veteran was diagnosed with a left shoulder sprain. The Veteran reported that he has been treated for pain in both shoulders. The Veteran reported feeling a popping sensation, stinging pain, weakness, and fatigue in both shoulders. These symptoms were aggravated during periods of overhead work/reaching. 

Unfortunately, the April 2017 VA examiner did not address the etiology of the Veteran's diagnosed left shoulder disability; however, this is not fatal to the Veteran's appeal.  The Board finds that the Veteran has provided competent, credible, and probative statements regarding the onset of his bilateral shoulder symptoms in service with continuing treatment following his discharge. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (holding that laypersons are competent to report lay observable symptoms and information of which they have personal knowledge). The Veteran indicated 'Yes' to having shoulder pain on the July 2016 separation examination. Next, he filed a claim for service connection while in service reporting that he had joint pain in his bilateral shoulders. Further, the VA treatment records show that he sought treatment after service for his continuing current bilateral shoulder disabilities. Moreover, the Veteran did suffer a functional loss due to pain in both shoulders. The Veteran's statements are generally consistent with the subsequent treatment records. 

Critically, the above facts were noted by the April 2017 VA examiner, and while an etiology for the disability was not addressed, the examiner did not point to any evidence of an intervening, post-service shoulder injury or rule out the possibility that the Veteran's current left shoulder disability was incurred during active duty.  

Given the foregoing, and resolving all reasonable doubt in the Veteran's favor, the Board finds that it is at least as likely as not that the Veteran injured his left shoulder in the first documented in-service fall. The Board recognizes that the Veteran has consistently reported the incident throughout the adjudication of his claim.

Accordingly, the Board finds that the evidence for and against the claim is at least in equipoise. Therefore, reasonable doubt must be resolved in favor of the Veteran and entitlement to service connection for a left shoulder disability, diagnosed as a left shoulder sprain, is warranted. 38 U.S.C. § 5107(b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

 

SCOTT W. DALE

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	C. Ivan Franklin

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.