Citation Nr: 21006260 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 11-11 587 DATE: February 3, 2021 REMANDED Entitlement to service connection for a low back condition is remanded. Entitlement to service connection for a left shoulder (minor) condition is remanded. REASONS FOR REMAND The Veteran had active duty service from May 1987 to January 1991 and several periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) service in the U.S. Air Force Reserves. In July 2017, the Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge. In a November 2017 Decision, the Board remanded the issues herein for further development and adjudication. 1. Entitlement to service connection for a low back condition The November 1986 enlistment examination did not document any abnormalities of the low back or left shoulder. During the July 2017 Board hearing, the Veteran testified that he has experienced chronic left shoulder and low back pain over the years with the ongoing training and duties required as an aircraft mechanic during his ACDUTRA periods in the Reserves; the Veteran further testified that his low back and left shoulder disabilities had their onset prior to Reserve duty, but were aggravated during periods of ACDUTRA by the wear and tear of years of lifting, climbing, and other aspects of his job as an aircraft mechanic (which he performed for around 25 years). Notably, private treatment records indicate continued treatment for left shoulder and low back pain (which were not attributed to any particular injury) and the Board finds that the Veteran’s testimony regarding his duty requirements (lifting, climbing, training) are consistent with the circumstances of his military occupational specialty as an aircraft mechanic. Additionally, the Board notes that the Veteran, as a layperson, is competent to report lay-observable symptoms (including ongoing pain, self-treatment, and functional limitation). Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran was afforded pertinent, left shoulder and back examinations in December 2017. Regarding the left shoulder, the December 2017 examiner (Dr. SWS), in pertinent part: (a) diagnosed impingement syndrome in 1995, rotator cuff tear in 1995, and status post laparoscopic surgery in 2008; (b) noted that the condition had progressed since onset in 1995 with additional injury to the left shoulder in 2000; and (c) documented functional impact of inability to lift more than 15 pounds with the left shoulder. Regarding the low back, the December 2017 examiner (Dr. SWS), in pertinent part: (a) diagnosed L4/L5 disc herniation in 1995, status post discectomy and laminectomy in 2004, and bilateral lower extremity radiculopathy in 2004; (b) noted that the condition had progressed since onset in 1995; and (c) documented functional impact of inability to stoop to lift more than 15 pounds and inability to ambulate more than 15 minutes at a time. Although the December 2017 VA examiner rendered a seemingly favorable etiological opinion, the agency of original jurisdiction (AOJ) found it to be inadequate (based on the language used not being “legally approved” and for failure to address the Board’s November 2017 remand directives) and sought another opinion. See October 2019 Deferred Rating Decision. The Veteran was afforded another etiological opinion regarding the left shoulder and low back in May 2020. Regarding the left shoulder, the May 2020 examiner (Dr. MGN), in pertinent part: (a) noted that the Veteran did not have pertinent abnormalities during active service; and (b) opined that the left shoulder had not been aggravated beyond its natural progression by Reserve service, in pertinent part, because “there is NO documented complaint or treatment after the [V]eteran was fully recovered from the involved 06/27/2008 surgical procedures after 05/2009, one year later as predicted and documented by his Orthopedic Surgeon” and because he “has not had any significant documented complaint of his” left shoulder aside from his December 2017 VA examination that was conducted for claim purposes. Regarding the low back, the May 2020 examiner (Dr. MGN), in pertinent part: (a) noted that the Veteran did not have pertinent abnormalities during active service; and (b) opined that the low back had not been aggravated beyond its natural progression by Reserve service, in pertinent part, because the Veteran “has not had any documented back problems or complaints, evaluations[,] and/or treatments after 2006 when he was released to return to full duty regarding his lower back, post surgery, aside from his” December 2017 VA examination that was conducted for claim purposes. Unfortunately, the Board finds that remand is warranted for an addendum opinion because the May 2020 examiner failed to consider the Veteran’s probative statements from the July 2017 Board hearing regarding his chronic left shoulder and low back pain over the years (which is inconsistent with the examiner’s findings that the conditions resolved one year after the surgeries) and his ongoing duties for around 25 years that included lifting, climbing, and training; as such, addendum opinion is needed to consider this potentially favorable evidence. 2. Entitlement to service connection for a left shoulder (minor) condition This issue is remanded for the same reasons discussed above. The matters are REMANDED for the following action: 1. Examine the etiology of the left shoulder and low back conditions. The examiner must consider the Veteran’s credible statements from the July 2017 Board hearing regarding his chronic left shoulder and low back pain over the years (which is inconsistent with the May 2020 examiner’s findings that the conditions resolved one year after the surgeries) and his ongoing duties for around 25 years that included lifting, climbing, and training. 2. Readjudicate the appeal. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Daus, 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.