Citation Nr: 21074995 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 18-21 146 DATE: December 17, 2021 REMANDED Entitlement to service connection for a right shoulder condition is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1994 to December 2016, including in Iraq and Afghanistan. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2017 rating decision from a Department of Veteran's Affairs (VA) Regional Office (RO). A hearing was held before the undersigned Veteran's Law Judge in August 2021; a transcript has been associated with the record. 1. Entitlement to service connection for a right shoulder condition is remanded. The Veteran asserts his right shoulder condition began in service and has progressively worsened since that time. The Veteran's service treatment records show he reported right shoulder pain while in service. He was offered a VA examination in September 2016 in which the VA examiner declined to provide a diagnosis for the Veteran's right shoulder condition. The examiner indicated that the Veteran underwent imaging studies of his right shoulder; however, the result of those studies is not contained in the Veteran's record nor in his VA medical records. The Veteran continued to seek treatment for his right shoulder pain through the VA medical system. In June 2018 through March 2020, the Veteran reported chronic neck, back, and right shoulder pain. The Veteran was afforded a hearing in August 2021. The Veteran asserts his right shoulder condition has progressively worsened since its onset in service with no relief at any point. The Veteran asserts he was actively participating in physical therapy prior to the mandatory disallowance of in person medical appointments due to COVID-19 in March 2020. The Veteran further asserted that additional imaging of his right shoulder was discussed with his VA provider prior to the shutdown but have not yet been taken. The Veteran further asserts that his shoulder condition could be a result of his service-connected cervical spine and lumbar spine conditions. For secondary service connection claims, an examination is required where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) a service-connected disability; (3) an indication that the disability or symptoms of disability may be associated with the service-connected disability; but (4) insufficient competent medical evidence on which to decide the claim. McLendon v. Nicholson, 20 Vet. App. 79, 85-86 (2006). The Veteran has consistently asserted right shoulder pain throughout the entirety of the appeal period. Additionally, the Veteran is service connected for lumbar degenerative disc disease and cervical disc arthropathy. The Veteran's VA medical records show he experiences radiating pain primarily on his right side. There is no medical opinion of record that considers the Veteran's right shoulder pain in relation to his lumbar and cervical spine conditions. As a result, the Board finds that an additional examination, to include imaging studies of the right shoulder, is warranted prior to adjudicating the claim. Additionally, the Veteran's military personnel records show he served in Afghanistan from January 2012 to January 2013 and Iraq from February 2003 to August 2003. Therefore, he is considered a Persian Gulf Veteran. 38 C.F.R. § 3.317(e). The Veteran reports experiencing chronic right shoulder pain during and since his active-duty service. At this point, the Veteran has not been fully evaluated to determine whether or not his chronic right shoulder condition could be considered an undiagnosed illness related to his service in Afghanistan and Iraq. On remand, the Veteran's right shoulder condition should be considered in relation to his Persian Gulf service. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his right shoulder condition. The examiner must review the entire claims file. Imagine studies must be performed and considered prior to providing a medical opinion. The examiner should conduct all appropriate diagnostic testing. The examiner should then record all noted signs and reported symptoms, document all clinical findings, and provide a diagnosis if possible. The examiner is asked to provide responses to the following: A) Identify the Veteran's objective indications of a disability. "Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost form work, the veteran having sought treatment for his symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). B) By history, physical examination, or laboratory testing, can the Veteran's objective indications of a disability be attributed to a known clinical diagnosis? If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should say so. C) If the Veteran's objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness was not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War? The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. D) If the Veteran's objective indications can be attributed to a known clinical diagnosis, 1) is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? 2) is the pathophysiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? These determinations each must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole. 3) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran's diagnosed condition a. was incurred in, or is otherwise related to, his active service? b. Is proximately due to his service-connected disabilities to include his service-connected cervical spine condition and/or lumbar spine condition? c. Is aggravated, i.e., worsened beyond its natural progression, by his service-connected cervical spine and/or lumbar spine condition? A complete rationale must be provided for all opinions expressed. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Associate Counsel, S. Conti 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.