Citation Nr: 21075999 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 16-07 581 DATE: December 22, 2021 ORDER The application to reopen the claim for service connection for a right shoulder condition is granted. To this extent only, the appeal is granted. The application to reopen the claim for service connection for a left shoulder condition is granted. To this extent only, the appeal is granted. REMANDED Entitlement to service connection for a left shoulder condition is remanded. Entitlement to service connection for a right shoulder condition is remanded. Entitlement to a rating in excess of 10 percent for right knee patellofemoral syndrome is remanded. Entitlement to a rating in excess of 10 percent for left knee patellofemoral syndrome is remanded. FINDING OF FACT A June 2011 rating decision denied service connection for bilateral shoulder conditions. The evidence received since the June 2011 rating decision is not cumulative or redundant and raises a reasonable possibility of substantiating the claim. CONCLUSIONS OF LAW 1. New and material evidence having been submitted, the claim for service connection for a right shoulder condition is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2020). 2. New and material evidence having been submitted, the claim for service connection for a left shoulder condition is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2020). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from December 1965 to December 1967 and from March 1968 to April 1992. He received the Army Service Ribbon; National Defense Service Medal with bronze service star; Parachutist Badge; Vietnam Service Medal; Vietnam Campaign Medal with "60" device; Army Commendation Medal with two oak leaf clusters; Bronzer Star Medal; Republic of Vietnam Gallantry Cross with palm; Recruiter Badge; Overseas Service Ribbon; Driver/Mechanic Badge with device; Army Good Conduct Medal; and Noncommissioned Officer Professional Development Ribbon. In the February 2016 appeal to the Board, the Veteran requested a videoconference hearing. The Veteran was notified that his videoconference hearing was scheduled for October 1, 2021. The Veteran failed to appear for the hearing, and he has not requested that the hearing be rescheduled. Accordingly, the Board considers the hearing request withdrawn. Application to Reopen The Veteran's claims for service connection for right and left shoulder disabilities were previously denied in a June 2011 rating decision. The Veteran timely appealed the denial, and the agency of original jurisdiction (AOJ) issued a statement of the case (SOC) in September 2013. The AOJ determined that the evidence failed to show an event or injury in service. The Veteran did not timely perfect his appeal; therefore, the June 2011 decision became final. Since that final decision, the Board finds that new and material evidence has been associated with the claims file. Specifically, the Veteran's DD 214 shows that he was awarded the Parachutist Badge. See August 2014 Certificate of Discharge, p. 1. The Board finds that the newly added evidence reasonably raises the possibility that the Veteran's bilateral shoulder conditions may be etiologically related to his active duty service, and the Board will reopen the claims. See Shade v. Shinseki, 24 Vet. App. 110, 118 (2010); see also Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998) (noting that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant the claim). REASONS FOR REMAND Service Connection for Right and Left Shoulder Disabilities The Veteran contends that his shoulder disabilities are related to injuries sustained during a parachute jump during his active duty service. See May 2015 Notice of Disagreement, p. 2. In August 2015, the Veteran underwent a VA examination, and the examiner offered a negative nexus opinion. See October 2015 VA Examination, p. 29. The examiner's opinion is based on an absence of medical records indicating continuity of care between 1992 and 2009. However, the examiner's opinion does not consider the Veteran's reports of self-treating his injuries with ice and Motrin (since 1976) nor does the examiner address the Veteran's report of sustaining injuries in an in-service parachute jump. Moreover, an October 1997 treatment record shows that the Veteran was seen for bilateral shoulder pain. See October 2015 VA Examination, p. 6. Accordingly, the Board finds that a new opinion is needed. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Increased Rating for Bilateral Patellofemoral Syndrome The Veteran's VA treatment records indicate that the Veteran receives care for his service-connected knee disabilities from a non-VA provider. See November 2019 CAPRI, pp. 36, 79. These treatment records are not yet associated with the claims file and appropriate efforts should be made to obtain such records on remand. See 38 U.S.C. § 5103A (2012). Moreover, the Veteran's VA treatment records suggest that his disability has worsened since his last VA examination in August 2015. Specifically, VA treatment records show that the Veteran complained of right knee pain in December 2016, see November 2019 CAPRI, p. 114, but his right knee was described as "asymptomatic" in August 2015. See October 2015 VA Examination, p. 17. Accordingly, on remand, the Veteran should be scheduled for an examination to ascertain the current severity of his bilateral patellofemoral syndrome. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007). The matters are REMANDED for the following action: 1. Obtain a medical opinion that addresses the nature and etiology of the Veteran's right and left shoulder conditions. If deemed necessary by the examiner, schedule the Veteran for an examination. Any indicated evaluations, studies and tests deemed necessary by the examiner should be accomplished. The entire claims file, to include a complete copy of this REMAND, should be made available to the examiner designated to provide an opinion, and the examination report should include a discussion of the Veteran's documented medical history and his assertions. The examiner should offer comments, an opinion and a supporting rationale that address the following: (a) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's right shoulder disability was incurred in, aggravated by, or is otherwise etiologically related to his active duty service? (b) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's left shoulder disability was incurred in, aggravated by, or is otherwise etiologically related to his active duty service? In providing these opinions, the examiner should specifically discuss the Veteran's in-service complaints of shoulder pain, reports of self-treating his injuries with ice and Motrin (since 1976), and the Veteran's report of sustaining injuries in an in-service parachute jump. See January 2015 VA Treatment Records, p. 57; March 2015 VA Treatment Records, pp. 21, 22. The examiner should also consider the October 1997 treatment for bilateral shoulder pain. See October 2015 VA Examination, p. 6. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. 2. Provide the Veteran with the appropriate release forms to identify and obtain any outstanding private treatment records related to his service-connected bilateral knee conditions. All efforts to obtain such records should be documented. 3. Schedule the Veteran for an examination to assess the severity and manifestations of his bilateral patellofemoral syndrome. Any indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The entire claims file, to include a complete copy of this REMAND, should be made available to the examiner designated to provide an opinion. The examiner should report all signs and symptoms necessary for evaluation of the Veteran's knee disabilities under the rating criteria. The examiner must comment as to whether there is pain, weakened movement, excess fatigability, or incoordination on movement. The examiner should also note the degree to which any additional range of motion is lost due to (1) pain on use, including during flare-ups; (2) weakened movement; (3) excess fatigability; or (4) incoordination. (Continued on the next page) The examiner must glean information from the Veteran, his medical records, and any other available sources regarding any additional functional impairment that results during flare-ups or following repeated use over time. The examiner must provide the estimated degree to which range of motion is lost during a flare-up or following repeated use over time. Efforts to obtain such information must be documented. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board W.V. Walker, 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.