Citation Nr: 21074613 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 14-15 468A DATE: December 15, 2021 REMANDED Entitlement to service connection for degenerative joint disease of the left shoulder (also claimed as bone spurs of the left shoulder) is remanded. Entitlement to service connection for a posterior calcaneal spur of the right foot is remanded. Entitlement to service connection for a posterior calcaneal spur of the left foot (claimed as left foot bone spur and as left ankle bone spur) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1972 to December 1979. The Veteran passed away in November 2020, and his spouse has been recognized as the substitute Appellant. This case comes before the Board of Veterans' Appeals (Board) on appeal from April 2012 and January 2014 rating decisions from the Regional Office, which denied, in pertinent part, service connection for degenerative joint disease of the left shoulder and service connection for posterior calcaneal spurs of the bilateral feet. In April 2018, the Board issued a decision that, among other things, denied entitlement service connection for the left shoulder and for bilateral calcaneal spur. The Veteran appealed the denial to the Court of Appeals for Veterans Claims (Court). In a June 2019 Order, pursuant to a Joint Motion for Remand (JMR) filed by the parties, the Court vacated and remanded the April 2018 decision for compliance with the instructions in the JMR. This matter was last before the Board in July 2021, when it was remanded for further development. The Veteran contended that his bilateral foot and left shoulder disabilities were related to service. He first reported shoulder pain while on active duty in May 1972 after a sports injury. He was diagnosed with a probable torn muscle. He reported shoulder pain at other times during his service and received another x-ray in August 1979 that showed no acute fracture or dislocation, but suggested soft tissue swelling above the lateral shaft of the humerus. In December 2010, he reports ongoing left shoulder pain since 1972. In May 2015, the Veteran and his representative reported that residual symptoms and complaints of swelling and severe pain from his in-service left shoulder injury, became chronic the rest of his miliary career. In its July 2021 remand, the Board directed the examiner to address among other things, the above December 2010 and May 2015 reports. Regarding the Veteran's bilateral foot calcaneal spur, the July 2021 remand instructed the examiner to discuss and concede as true the Veteran's statements as to an in-service right foot/right ankle injury, and that he has experienced continuous pain, with dull pain in both heels, and swelling in the right foot along with discomfort, since that time. Despite the Board's clear instruction, the September 2021 VA medical opinion do not reflect adequately consideration of the Veteran's lay statements concerning the onset and continuity of symptoms. Instead, although the examiner mentioned a review of those statements and the remand directives, the supporting rationale relies exclusively on a lack of documentation in the Veteran's service treatment records without further explanation. When a veteran has provided competent lay statements of ongoing pain since 1972, the examiner must consider and address them when developing his rationale. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). The Board must ensure compliance with the directives of a prior remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). As such, another remand is necessary. The matters are REMANDED for the following action: 1. Obtain an VA medical opinion addressing the whether the Veteran's currently-diagnosed left shoulder disorder is related to his military service. The entire claims file should be made available to the examiner. After a review of the claims file, including the lay statements provided by the Veteran, the examiner should address the following: Is it at least as likely as not (50 percent or greater probability) that the Veteran's left shoulder acromioclavicular arthropathy, degenerative joint disease, and/or spurs had its/their onset in service, or is otherwise related to service, to include as a result of documented treatment therein? In providing the requested opinion, the examiner is asked to review and comment on the following: Veteran has reported ongoing left shoulder pain since 1972. See e.g., December 2010 VA treatment record. Address the Veteran's contention that his shoulder spurs are caused by running exercises in boot camp (see May 2011 VA Form 21-4138). Address the Veteran's contention that the residual symptoms and complaints of swelling and severe pain from his in-service left shoulder injury became chronic the rest of his military career (see May 2015 IHP). Address the May 1972 STR notation that he injured left shoulder and that it is probably a torn muscle. Address the August 1979 STR report of swollen or painful joints and address the August 1979 STR report of a left shoulder torn ligament. Address the March 1979 STR regarding sharp pain in the left shoulder after pulling a muscle in the neck. Address the August 1979 STR of left shoulder pain and a previous injury in 1972 and the statement from the Veteran's fellow service member that the Veteran suffered a left shoulder injury in July 1997 while at Ft. Riley, Kansas, and the Veteran wore a sling due to the same (see March 2015 Lay Statement). In offering any opinion, the clinician must consider the full record, to include the Veteran's lay statements regarding in-service incurrence and continuity of symptomatology, and the opinion should reflect such consideration. If the clinician rejects the Veteran's lay statements, the clinician must provide reasons for doing so, and lay statements must not be rejected due solely to an absence of contemporaneous or corroborating medical evidence, although this may be considered together with the other evidence of record. A complete rationale must be provided for all opinions and must be based on consideration of all pertinent lay and medical evidence. A complete rationale shall be given for all opinions and conclusions expressed. 2. Obtain an VA medical opinion addressing the whether the Veteran's currently-diagnosed right foot calcaneal spur, left foot calcaneal spur, and left ankle deltoid ligament sprain are related to his military service. The entire claims file should be made available to the examiner. After a review of the claims file, including the lay statements provided by the Veteran, the examiner should address the following: a) Is at least as likely as not (50 percent or greater probability) that the Veteran's right foot calcaneal spur, left foot calcaneal spur, and/or left ankle deltoid ligament sprain had their onset in service, or is otherwise related to service, to include as a result of documented treatment therein. In providing the requested opinion, the examiner is asked to review and comment on the following: Discuss and concede as true the Veteran's statements as to an in-service right foot/right ankle injury, and that he has experienced continuous pain, with dull pain in both heels, and swelling in the right foot along with discomfort, since that time (see April 2012 NOD, February 2015, January 2020 VA examination). Address the Veteran's contention that his bilateral foot bone spurs are caused by running exercises in boot camp (see May 2011 VA Form 21-4138). b) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's diagnosed right foot calcaneal spur, left foot calcaneal spur, and left ankle deltoid ligament sprain are either caused or aggravated by his service-connected right ankle disability. Please note that causation and aggravation are two separate inquiries, and both much be answered. In addressing these questions, please address the Veteran's contention that he had a right foot/ankle injury which caused spurs on his bilateral feet/left ankle (see April 2013 Correspondence, May 2015 IHP). In offering any opinion, the clinician must consider the full record, to include the Veteran's lay statements regarding in-service incurrence and continuity of symptomatology, and the opinion should reflect such consideration. If the clinician rejects the Veteran's lay statements, the clinician must provide reasons for doing so, and lay statements must not be rejected due solely to an absence of contemporaneous or corroborating medical evidence, although this may be considered together with the other evidence of record. A complete rationale must be provided for all opinions and must be based on consideration of all pertinent lay and medical evidence. (CONTINUED ON NEXT PAGE) 3. Thereafter, readjudicate the issues on appeal. James Springer Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Asare, Associate Counsel 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.