Citation Nr: 21076261 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 15-09 812 DATE: December 22, 2021 REMANDED Entitlement to a left shoulder disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1970 to December 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision issued by the Department of Veterans Affairs (VA), Regional Office (RO). This matter was previously remanded by the Board in June 2018 and again in October 2019. Thereafter, a July 2020 Board decision denied the claim for service connection. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court). Counsel for the Veteran and the Secretary of VA (the parties) filed a Joint Motion for Remand (JMR). An Order of the Court dated July 2021 granted the motion and remanded this issue to the Board. 1. Left shoulder disorder The Board is remanding this matter for actions consistent with the July 2021 JMR. First, the July 2021 JMR determined that the Board did not comply with VA's duty to assist when it failed to ensure all relevant treatment records pertaining to this claim were associated with the claims file. Specifically, the JMR noted that VA treatment records dated prior to 2010 from the Plattsburg, New York Community Based Outreach Clinic (CBOC), and the Albany, New York VA Medical Center (VAMC), were not included in the claims file. Therefore, all records from these and any other VA facilities from which the Veteran received treatment for this disorder prior to 2010 must be obtained and associated with the claims file. Second, the JMR notes that the Veteran was not provided an adequate VA examination, but also did not specifically identify the deficiencies in the prior January 2012 VA examination report and opinion and the March 2019 addendum opinion. Nevertheless, in accordance with the JMR, the Veteran must be scheduled for a VA examination and opinion to determine the nature and etiology of the diagnosed left shoulder disorder. The matters are REMANDED for the following action: 1. Obtain all of the Veteran's outstanding VA treatment records dated prior to 2010 from the Plattsburg, New York CBOC and the Albany, New York VAMC. 2. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination regarding the etiology of any currently diagnosed left shoulder disorders. Following a review of the record, to include the evidence provided in the prior June 2018 Board Remand (incorporated below), the examiner is asked to address the following: (a.) Identify any and all currently diagnosed left shoulder disorders. (b.) For each identified disorder, please state whether it is at least as likely as not (50 percent or greater probability) whether it had its onset during or was causally related to his military service, to include an injury to one or both shoulders in November 1970? In determining whether the Veteran's left shoulder disorder is related to his military service, the clinician should review the claims file and specifically address the following: 1. The November 17, 1970, Individual Sick Slip stating, "injury to shoulder" and "no lifting (heavy) w L arm x 1 week;" 2. The April 20, 1971, request for an examination of the Veteran's left and right shoulders noting "it is the left AC-joint which is somewhat wider;" 3. The April 2011 written statements from the Veteran describing the 1970 injury and his subsequent pain and functional limitations; and, 4. The April 2011 written statements from the Veteran's friends and family regarding their observations of the Veteran's symptoms of a left shoulder disability. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be acknowledged and considered in formulating any opinion. Furthermore, if medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. 3. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Berry, 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.