Citation Nr: 21007356 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 14-34 273 DATE: February 9, 2021 REMANDED Entitlement to service connection for a bilateral shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1999 to December 2006. The matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2013 rating decision. The Veteran requested a hearing before the Board, and such was scheduled in April 2019; however, the Veteran did not appear for the hearing. He has not requested that such be rescheduled. As such, the Board considers the Veteran’s request for a hearing satisfied, and the Board will proceed with adjudication. The Board adds that the Veteran also perfected an appeal for service-connection claim for a bilateral knee disability. However, prior to certifying the appeal to the Board, the agency of original jurisdiction (AOJ) granted entitlement to service connection for disabilities of both knees in a March 2017 rating decision. As such, the matters are no longer in appellate status. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159. The Veteran asserts that his bilateral shoulder disability began in service. As noted above, he discharged in December 2006. The Veteran contends the military lifestyle intensified the pain throughout his time in service, through running, heavy lifting, and the other physical demands of the Army. He contends that he first noticed his chronic shoulder pain in Iraq in 2003 and that, after the chronic pain persisted, he sought medical attention from his unit medical clinic where he was first diagnosed with arthritis. He states that it directly affected his mobility and continued to do so. He contends that in 2008 when he was seeking further treatment from his VA outpatient clinic, he was diagnosed specifically with osteoarthritis in both of his shoulders. He has also stated that he is currently prescribed anti-inflammatory medication to treat pain associated with osteoarthritis in his shoulders, that he has seen physical therapy and surgery was recommended, and that an MRI has shown osteoarthritis. See May 2012 VA Form 21-526; see also May 2014 VA Form 21-4138. As an initial matter, there is no dispute that the Veteran has a current bilateral shoulder disability. See August 2016 VA treatment records. Regarding the second requirement for service connection, an in-service event, the Veteran’s service treatment records are silent as to treatment for a bilateral shoulder disability. However, the record indicates that the Veteran reported in January 2009 that he had been experiencing right shoulder pain for two years. See January 2009 VA treatment records. Additionally, the record notes a history of shoulder pain without specificity as to whether it was the left or the right shoulder. See September 2010, September 2011, and August 2012 VA treatment records. The Veteran is competent to report symptoms as they come to him through his senses. Layno v. Brown, 6 Vet. App. at 469. As part of its duties to assist a Veteran in a claim for service connection, VA may be required to provide an examination. Such an exam is required when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the claimant’s service or with another service-connected disability, and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, the Board finds that there is competent evidence to suggest that there may be a link between the Veteran’s claimed condition and his active duty service. As such, the Board finds that the evidence of record surpasses the “low” threshold set forth in McLendon. On remand, a VA examination should be scheduled, and an opinion obtained addressing the etiology of the Veteran’s bilateral shoulder disability. Insofar as the Veteran notes that he received treatment for his shoulders in the years immediately following his discharge, the Board observes that the first VA treatment records on file date from January 2009. A January 16, 2009 VA treatment note indicates that the visit on that date was to establish care at VA, and notation within the report indicated prior primary care with Dr. B. at the Sadler Clinic. On remand, the Veteran should be asked to submit, or authorize VA to obtain on his behalf, all records of private care that are not already associated with the record, to include records from Dr. B. The matter is REMANDED for the following action: 1. Send the Veteran a letter requesting that he submit, or authorize VA to obtain on his behalf, any records of private care for his bilateral shoulders that are not already part of the record, to include records from Dr. B. at the Sadler Clinic dating from 2006 to the present. Take all appropriate steps to secure identified private records. 2. Ask the Veteran to indicate if he sought care at any VA facility other than the Conroe Community Based Outpatient Clinic (CBOC) prior to January 2009, and if so, at what facility or facilities. Take all appropriate steps to obtain and associate with the file all identified VA records. 3. Schedule the Veteran for a VA shoulder examination to address the nature and etiology of his current bilateral shoulder disability. The claims file should be sent to, and reviewed by, the VA examiner. The examiner should take a history from the Veteran as to the progression of his bilateral shoulder disability. Following review of the file, interview and examination of the Veteran, the examiner is asked to address the following: a) Identify all current bilateral shoulder disabilities. b) For each disability, is it at least as likely as not (50 percent or greater probability) that such had onset in, or is otherwise related to active duty service, to specifically include wear and tear from the physical rigors of his service? c) If arthritis did not have onset during service, or is not otherwise related to service, is it at least as likely as not that the Veteran has arthritis that manifested within the Veteran’s first post-service year (i.e., between December 2006 to December 2007)? All opinions should be supported by a medical explanation or rationale. (Continued on Next Page) 4. Then, readjudicate the issue on appeal. If the claim remains denied, send the Veteran a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Fulmer, 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.