Citation Nr: 21007479 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 15-34 009 DATE: February 9, 2021 REMANDED Entitlement to service connection for a right shoulder disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1980 to October 1994. In January 2019, he and his wife testified during a hearing at the RO before the undersigned. A transcript of the hearing is of record. In June 2019, the Board issued a decision that denied service connection for right shoulder disorder. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (CAVC). In a June 2020 Order, pursuant to a Joint Motion for a Partial Remand (JMPR) filed by the parties, the Court vacated and remanded the June 2019 decision for compliance with the JMPR. The Veteran is seeking service connection for a right shoulder disorder that he asserts is the result of lifting heavy batteries and generators. He testified that in the military he served as a fuel assistant repairman and that his duties included repairing heavy-duty starters, alternators and generators. He also worked in the shop charging and refueling batteries weighing 50 to 80 pounds. The Veteran testified that he first sought treatment for his right shoulder in 1995 or 1996. See January 2019 Board hearing transcript. The Veteran’s DD-214 confirms his military occupational specialty (MOS) as a fuel and electrical system repairman. Additionally, his service treatment records show that in April 1985 he was treated for low back and right shoulder pain, which he described as a constant dull ache that became sharp upon abduction and rotation. The clinical impression was musculoskeletal strain. A December 1990 periodic evaluation did not indicate any complaints, treatment, or diagnosis related to the Veteran’s right shoulder. An April 1992 entry indicates that the Veteran complained of right forearm pain, with no mention the shoulder. A July 1994 entry reflects treatment for an unrelated right arm wound, noted as treatment for a growth under his right arm. The Veteran’s August 1994 separation examination was silent for any complaints, treatment, or diagnosis related to his right shoulder. Post-service medical treatment records reflect that the Veteran sought treatment in October 1996, July 1998, August 2000, and January 2001; however, none of these visits included complaints, treatment, or a diagnosis related to his right shoulder. The earliest documentation of right shoulder complaints is in January 2009 when he reported right shoulder pain for approximately one week; he indicated that he was working as a diesel mechanic and lifted relatively heavy objects for work, but he did not recall a specific injury. The diagnosis provided was atraumatic right shoulder pain and rotator cuff tendonitis. There is also X-ray evidence of degenerative arthrosis of the right AC joint. However, a July 2013 VA examiner concluded the Veteran did not have a shoulder or arm condition and that it was unlikely that his current right shoulder pain was related to injury from lifting heavy batteries and generators during service because there was no noted record of significant injury during service. The examiner also noted the Veteran reported a post-service right shoulder injury diagnosed as a strain. Since that examination the Veteran’s attorney, has challenged the adequacy of that examination on the basis that the VA examiner failed to specifically discuss the April 1985 service treatment record where the Veteran complained of right shoulder pain or take into account the January 2009 post-service diagnosis of right shoulder osteoarthrosis. Generally, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this case, the record is currently insufficient to decide this claim and further development is needed. By this remand, the Board makes no determination, express or implied, as to the credibility of any statements on file. The matters are REMANDED for the following action: Schedule the Veteran for appropriate VA examination. The examiner must consider the right shoulder diagnoses already of record, including strain, osteoarthrosis, rotator cuff tendonitis, and degenerative joint disease and must offer an opinion even if a diagnosis has resolved (as the requirement for a current disability for VA purposes is met when the Veteran has a diagnosis such that he based his claim on the same, or had it during the pendency of the claim). The examiner should discuss: 1) the objective medical findings in the service treatment records including the April 1985 entry documenting the Veteran’s right shoulder strain; 2) the Veteran’s post-service employment as a diesel mechanic; 3) the post-service shoulder injury in 2009; 4) the June 2013 VA examination report; and 5) the Veteran’s theory that heavy lifting associated with his military duties may have caused or contributed to his current shoulder problems disorders. [Note: The examiner is reminded the Veteran is competent to describe his subjective experiences and his lay statements must be considered in formulating the requested opinion]. The examiner should then state whether it is at least as likely as not, (a probability of 50 percent or greater), the Veteran’s documented right shoulder musculoskeletal strain in 1985 represents the earliest manifestation of any currently diagnosed right shoulder disorder. If any diagnosed right shoulder disorder cannot be regarded as having had its onset during active service, the examiner should explicitly indicate so and address whether the Veteran’s current right shoulder disorders are due to intercurrent causes unrelated to his military service, such as post-service employment as a diesel mechanic. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.R. Bryant 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.