Citation Nr: 21077633 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 19-02 880A DATE: December 30, 2021 ORDER Entitlement to service connection for a right shoulder rotator cuff tear and labral tear including superior labral anterior-posterior (SLAP) lesion is granted. Entitlement to service connection for a lumbar spine condition is granted. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, his right shoulder rotator cuff tear and labral tear including SLAP lesion is related to active service. 2. Resolving reasonable doubt in the Veteran's favor, his lumbar spine condition is related to active service. CONCLUSIONS OF LAW 1. The criteria for service connection for right shoulder rotator cuff tear and labral tear including SLAP lesion are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a lumbar spine condition are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1976 to May 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is associated with the claims file. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). VA is responsible for determining whether the evidence supports the claim, with the veteran prevailing, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). 1. Entitlement to service connection for a right shoulder rotator cuff tear and labral tear including SLAP lesion The Veteran asserts that he is entitled to service connection for a right shoulder disability. The Board concludes that the Veteran has a current right shoulder disability that is related to an in-service injury. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). VA examination reports show the Veteran has a current diagnosis of right rotator cuff repair, labral repair, SLAP tear with residual pain and loss of range of motion. Service treatment records from November 1980 show the Veteran reported he injured his right shoulder and arm while moving a waterbed. He was assessed as having a pulled muscle. The Veteran sought treatment for a dull ache in his right shoulder in May 1982. In September 1982 the Veteran complained of pain when raising his right arm, but a radiology report indicated the right shoulder was normal. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of and against the claim. The evidence against the claim includes a November 2017 VA medical opinion. During the examination, the Veteran stated that his right shoulder symptoms onset in 1980, and have continued to worsen. The examiner opined that it was less likely than not that the Veteran's right shoulder condition was incurred in or caused by service. In support of the opinion, the examiner explained that there was no chronic right shoulder condition identified in service, at service separation, or in close proximity to service. The examiner further stated that service treatment notes regarding the right shoulder are supportive of an acute condition and do not support a chronic, ongoing condition. Additionally, the examiner noted that there was no continuity of symptoms since service, and post-service records indicate the right shoulder condition became evident many years after service. In September 2018, another VA examiner also opined that the Veteran's right shoulder condition was not related to his military service. During the examination, the Veteran reported that he fell down a stairwell while moving a waterbed and injured his right shoulder. The Veteran stated he treated the pain with over-the-counter medication, but it progressively worsened over the years and he sought medical treatment in 2003. The examiner acknowledged the Veteran's in-service reports of and treatment for right shoulder and arm pain, but determined that his current shoulder issues were not related to his service. He noted that there was no evidence of chronicity or complaints since service. The evidence in favor of the claim includes post-service private treatment records from November 2016, showing the Veteran was seen for right shoulder pain that had persisted for several years. The Veteran stated he believed the pain was related to his time in the military. In February 2017, the Veteran underwent surgery to repair the right shoulder. Further, at the Board hearing, the Veteran testified that he injured his right shoulder in while in service, and has dealt with pain since that time. He stated he has mostly gone without care for the right shoulder because he could not afford to take the time off from work. The Board finds the Veteran is competent and credible to testify and report that he experienced pain since service because it is a symptom readily observable through his senses. See Layno v. Brown, 6 Vet. App. 465, 471 (1994). The Veteran also submitted an April 2018 opinion from Dr. R.P., his private physician, in support of his claim. Dr. R.P. stated he has treated the Veteran since 2003, and reviewed his medical records, including service treatment records. He acknowledged that during service, the Veteran was treated for pain, numbness, and weakness of the right shoulder. Dr. R.P. explained that the Veteran's current right shoulder problems date back to his time in service, and he has continued to have right shoulder pain. He opined that it was more likely than not that the physical traumas suffered during military service caused and contributed to his current right shoulder condition. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current right shoulder condition is related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for right shoulder rotator cuff tear and labral tear including SLAP lesion is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for a lumbar spine condition The Veteran also asserts that he is entitled to service connection for a lumbar spine condition. The Board concludes that the Veteran has a current lumbar spine disability that is related to service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). VA examination reports show the Veteran has current diagnoses of degenerative disc disease and lumbar strain. During service, the Veteran was seen in November 1982 for low back pain after injuring himself while out in the field. The examining physician determined it was a muscular issue. The following month, the Veteran was seen again for low back pain and was noted to have localized tenderness. An undated report of medical history shows the Veteran stated he was treated for his back in December 1982 and that he continued to have back aches at times. The question before the Board is whether the current disability is related to service. There are probative opinions in favor of and against the claim. The evidence against the claim includes a November 2017 VA medical opinion. The Veteran explained to the examiner that his back symptoms began in 1982 when he hurt his back while performing heavy lifting in service. He stated the condition has worsened since that time. The examiner opined that it was less likely than not that the Veteran's current back condition was incurred in or caused by service. As rationale, the examiner stated there is no chronic lower back condition identified in service. The examiner noted the Veteran was treated for lower back pain in service, but the condition was not noted at service separation, and the evidence does not support a finding of continuity of symptoms. In September 2018, another VA examiner provided a medical opinion. The Veteran again reported that he injured his back in service, and has since had episodes of back tightness and pain. The examiner opined that it was less likely than not that the Veteran's current back condition was incurred in or caused by service. He explained that he was unable to link the Veteran's current degenerative disc disease to his time in service, as his muscle spasms were treated during service. The examiner concluded that the medical evidence does not support a relationship between the two conditions. The evidence in favor of the claim includes the Veteran's testimony during the Board hearing. He testified that he has dealt with chronic back pain since he left service, which he is competent to report. See Layno, 6 Vet. App. at 469 (1994). Additionally, Dr. R.P., the Veteran's treating physician, stated he reviewed the Veteran's medical records, including his service treatment records. He noted that the Veteran initially injured his back while in the military, and that the Veteran currently suffers from low back pain due to disk bulging and degenerative changes. Dr. R.P. opined that it is more likely than not that the physical trauma the Veteran suffered during service in 1982 caused and contributed to his current back condition. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current lumbar spine disability is related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for lumbar spine condition is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Miller, 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.