Citation Nr: 21074982 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 17-22 594 DATE: December 16, 2021 REMANDED Entitlement to service connection for left knee condition is remanded. Entitlement to service connection for left shoulder condition, to include as due to service-connected neck condition, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from October 1967 to September 1969. In April 2020, the Board of Veterans' Appeals (Board) remanded the issues of entitlement to service connection for left knee and left shoulder conditions for further development. Specifically, the Board instructed the regional office (RO) to schedule the Veteran for VA examinations pertaining to his claims. In December 2019, the Veteran testified at a videoconference hearing before the undersigned. A transcript of the hearing is associated with the claims file. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c). 38 U.S.C. § 7107(a)(2). Upon review of the record, the Board finds that the claims must be remanded. The Board sincerely regrets the additional delay caused by this remand but wishes to assure the Veteran that it is necessary for a full and fair adjudication of his claims. 1. Entitlement to service connection for left knee condition is remanded. The Board finds that a new VA examination and etiological opinion is warranted for the Veteran's claim. The Veteran contends that his left knee condition is the result of his active service, specifically from a 1969 parachute jump. The Veteran appeared for a VA examination in July 2021. Though the examiner acknowledged the Veteran's lay statement of self-medication with alcohol and other pain medications, he opined that the Veteran's left knee condition was less likely than not related to his service. In support of his opinion, the examiner noted that the Veteran's service/medical records showed no diagnosis upon discharge from service, that the August 1969 separation report of medical examination indicated no medical conditions, and that the 1969 notation of injury showed no indication of injury to the knee. An addendum opinion provided by the July 2021 examiner was associated with the Veteran's claims file in October 2021. He stated that his assessment was an evaluation of the evidence available more than an opinion and that minimal evidence was available. Further, he offered no commentary on the credibility of the Veteran. First, the Board finds that both the July 2021 opinion and the October 2021 addendum opinion failed to meaningfully address the competent and credible lay statements of record regarding the onset of pain in the Veteran's left knee and that he self-medicated. The Veteran is competent to report symptoms within the realm of his personal knowledge, such as left knee pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Second, as noted by the request for an addendum opinion, a lack of documentation in service treatment records (STRs) or in post-service records is not sufficient in and of itself to discredit the Veteran's testimony concerning the onset and history of symptoms. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (lack of contemporaneous medical records, standing alone, is not an adequate basis for a negative opinion). Accordingly, a remand for a new examination and opinion is warranted. 2. Entitlement to service connection for left shoulder condition, to include as due to service-connected neck condition, is remanded. The Board finds that a new VA examination and etiological opinion is warranted for the Veteran's claim. The Veteran contends that his left shoulder condition is related to service, specifically from parachute jumps. A July 2021 medical opinion provided by a VA examiner from a review of records was associated with the Veteran's claims file in September 2021. The July 2021 examiner merely noted that the Veteran declined examination. As for direct service connection, the examiner provided the same opinion as the left knee condition. As for secondary service connection, he opined that the Veteran's left shoulder condition was less likely than not related to or aggravated by his service-connected neck condition because there was no causal connection associated between the initial 1969 neck injury and subsequent diagnoses of current shoulder condition. He noted the August 2017 documentation of cervical radiculopathy as the cause of shoulder pain and the December 2019 opinion from the Veteran's physician as to the possibility of the parachute accident causing an injury. Ultimately, he concluded that the shoulder condition did not have documented or direct medical connection with the Veteran's service as indicated by the August 1969 separation report of medical examination. An addendum opinion provided by the July 2021 examiner was associated with the Veteran's claims file in October 2021. He stated that his assessment was an evaluation of the evidence available more than an opinion and that minimal evidence was available. Further, he offered no commentary on the credibility of the Veteran. However, he stated that shoulder arthritis was not caused by cervical radiculopathy or neck injury but could be caused by a shoulder injury, and that one condition did not cause the other. The Board finds both the July 2021 opinion and October 2021 addendum opinion to be inadequate for adjudication purposes. First, the examiner failed to explain why the Veteran declined examination of his shoulder, while the Veteran was willing to undergo examination of his left knee condition. Second, the examiner failed to meaningfully address the Veteran's competent and credible lay statements regarding the onset of pain in his left shoulder. Third, as noted by the request for an addendum opinion, a lack of documentation in service treatment records (STRs) or in post-service records is not sufficient to discredit the Veteran's testimony concerning the onset and history of symptoms. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (lack of contemporaneous medical records, standing alone, is not an adequate basis for a negative opinion). Finally, though the examiner noted the August 2017 notation and December 2019 opinion that show the Veteran's shoulder condition may be related to his service-connected neck condition, he failed to address why he disregarded those medical records. Accordingly, a remand for a new examination and opinion is warranted. The matters are REMANDED for the following action: 1. Assist the Veteran in associating with the claims file any relevant outstanding treatment records. 2. Schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of the Veteran's left knee condition. The claims file should be made available to the examiner for review in connection with the examination. Based on review of the record and conducting an examination of the Veteran, the examiner should respond to the following: (a.) Obtain a detailed history of the Veteran's left knee condition, to include any and all symptomology. (b.) State whether it is at least as likely as not (i.e., at least a 50 percent probability) that the Veteran's left knee condition had its onset in or is related to service, to include a parachute injury in June 1969. The examiner must specifically address: The Veteran's lay statements that he dealt with the pain from his left shoulder condition by drinking alcohol and by taking pain medication, as well always landing on the left side of his body after parachute jumps because his equipment was on his right side; His STRs, which showed a parachute injury in June 1969. If there is any medical reason to doubt the statements provided by the Veteran, the examiner should fully explain the reason. The examiner must provide the rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. Schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of the Veteran's left shoulder condition. The claims file should be made available to the examiner for review in connection with the examination. Based on review of the record and conducting an examination of the Veteran, the examiner should respond to the following: (a.) Obtain a detailed history of the Veteran's left shoulder condition, to include any and all symptomology. (b.) State whether it is at least as likely as not (i.e., at least a 50 percent probability) that the Veteran's left shoulder condition had its onset in or is related to service, to include a parachute injury in June 1969. The examiner must specifically address: The Veteran's lay statements that he dealt with the pain from his left shoulder condition by drinking alcohol and by taking pain medication, as well always landing on the left side of his body after parachute jumps because his equipment was on his right side; His STRs, which showed a parachute injury in June 1969; The August 2017 and the December 2019 statements from the Veteran's private physician. If there is any medical reason to doubt the statements provided by the Veteran, the examiner should fully explain the reason. (c.) State whether it is at least as likely as not (i.e., at least a 50 percent probability) that the Veteran's left shoulder condition was caused or aggravated by the Veteran's service-connected neck condition. AN OPINION AS TO BOTH CAUSATION AND AGGRAVATION IS REQUESTED. (d.) If the examiner finds that the Veteran's left shoulder condition was aggravated by his service-connected neck condition, then he/she should specify the baseline level of disability of the left shoulder condition prior to aggravation due to the service-connected neck condition. Note that aggravation means any incremental increase in disability in the non-service-connected condition (i.e., any additional impairment of earning capacity) resulting from the service-connected condition. (Continued on the next page) The examiner must provide the rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. L. Park, 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.