Citation Nr: 21006649 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 10-01 319 DATE: February 4, 2021 REMANDED Entitlement to service connection for a left shoulder disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1986 to June 1990, with subsequent service in the National Guard during the period 1994 to 1996. This matter comes before the Board of Veterans Appeals (Board) on appeal of a rating decision issued by the Reno, Nevada, Department of Veterans Affairs (VA) Regional Office (RO) in July 2008 and Board remands in April 2012, July 2015, September 2016, May 2018, and August 2019. 1. Entitlement to service connection for left shoulder disorder is remanded. Although the Board regrets the additional delay, remand is required for an adequate VA examination. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The examiner was instructed to diagnose any present shoulder disabilities, to include an opinion as to whether there was a diagnosis of tendonitis. In the March 2019 VA examination, the examiner simply stated that there was no tendonitis of the left shoulder since 2007. The examiner did not state whether there were any other diagnosable shoulder disabilities. As such, remand is required to determine whether the Veteran has any diagnosable left shoulder conditions. The examiner then found that the claimed condition was less likely than not related to the Veteran’s active duty service. The provided rationale was that there were no medical records to show any symptoms or complaints of left shoulder pain. The Board notes that March 2003 medical treatment records noted a history of left shoulder pain while July 2007 records noted that the Veteran had myoclonic tetanic contractions of his left upper extremity at the shoulder. January 2008 VA records noted spasms in the left shoulder muscle and limitation of shoulder movement. The July 2012 VA examination noted that the Veteran had a decreased range of motion and pain in the left shoulder. April, May, and November 2018 VA treatment records noted complaints of pain in both shoulders and records into 2017 note a medical history of shoulder pain. The complaints of shoulder pain and symptoms in the medical treatment records undermine the examiner’s rationale that there was no evidence to support a left shoulder condition. As such, remand is required for a VA opinion that properly addresses whether the Veteran has any diagnosable left shoulder conditions and whether they are related to active duty service. The matters are REMANDED for the following action: 1. Request that the VA examiner, if available, who conducted the March 2019 VA examination and opinion provide an addendum opinion regarding the etiology of any diagnosed left shoulder disorder. If an examination is deemed necessary, one must be provided. The claims folder must be made available to the examiner. An explanation for all opinions expressed must be provided. First, the examiner must provide an opinion regarding whether there are any left shoulder musculoskeletal disorders present since 2007, including whether the Veteran has/had a diagnosis of tendonitis of the shoulders or a left shoulder pain that causes functional impairment of earning capacity. The examiner must address complaints of left shoulder pain and other symptoms within the claims file. Second, if there are such disorders, then for each diagnosed disorder the examiner must provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the disorder had onset in, or is otherwise caused by, the Veteran's military service. The examiner must address the following: (a) the service treatment records noting chronic shoulder dysfunction due to calcium deposits, probably supraspinatus tendonitis, possible bursitis, and normal x-rays; (b) October 1992 and September 1994 examinations in which the Veteran denied arthritis, rheumatism, bursitis, and a painful or "trick" shoulder, and clinical evaluation of the upper extremities and musculoskeletal system was normal; (c) 1995 private records that noted bilateral shoulder impingement; (d) 1998 private records that indicated an impression of acute cervical strain with wry neck and associated right shoulder discomfort; (e) normal x-rays in May 2002 private records; (f) March 2003 private records that indicated normal x-rays and a clinical impression of left shoulder strain; and (g) lay statements in which the Veteran reported he injured his shoulders in service when he fell off a bunk, and that he has had continuous shoulder problems since service. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ashley Ki 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.