Citation Nr: 21010234 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 14-22 506 DATE: February 24, 2021 REMANDED Entitlement to service connection for a right shoulder disorder is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Army from July 1991 to August 1993. He also served from October 2004 to January 2006. Additionally, the Veteran served in the Michigan Army National Guard until 2013. Although the Veteran has had his case remanded back to the agency of original jurisdiction (AOJ) twice before, the Board has determined that it needs to be remanded again for a more adequate VA medical examination. While the Board regrets the delay, the February 2020 VA examination fails to consider or mention the Veteran’s reported in-service injury from 2004. A Board remand confers on the claimant, as a matter of law, a right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for a right shoulder disorder is remanded. The Veteran contends entitlement to service connection for a right shoulder disorder. Specifically, the Veteran claims he is warranted service connection for right shoulder acromioclavicular and glenohumeral joint degenerative arthritis, also noted as a right shoulder disorder. The medical records show that the Veteran has a current right shoulder disability. The July 2016 VA examination and February 2020 VA examination both note that the imaging testing reveal degenerative changes and degenerative arthritis of the Veteran’s right shoulder. The service treatment records (STRs) also show the Veteran sustained a shoulder injury during the line of duty in 2001 by falling off a truck. The Veteran also reported a right shoulder injury when loading duffle bags into the back of a truck in 2004, noting a pop in the shoulder and feeling his right arm go numb. The Veteran was also seen for his right shoulder pain and right arm numbness in December 2009, July 2010 and August 2011 while in the National Guard. In January 2020, the Board issued a remand, finding that the June 2016 VA medical examination was inadequate. The Veteran was then afforded another VA examination in February 2020. The February 2020 VA examiner concluded that there was no medical nexus establishing causality between the current complaint and military service. The examiner also stated that there was no residual or chronic disability subject to service connection shown by service medical records or demonstrated by evidence following service. Furthermore, the examiner noted that the Veteran was not medically discharged from the military and the service records show that the Veteran was medically qualified complete his tour of duty. Finally, the examiner stated that the degenerative changes in the right shoulder are part of the normal aging process. However, the January 2020 Board remand directives asked for the new examiner to elicit a complete history from the Veteran and provide written consideration of the Veteran’s statements. The remand directives also stated that the examiner must opine whether the right shoulder disability is at least as likely as not related to an in-service injury, event, or disease, including the 2001 fall. The examiner did not properly follow the remand directives as the examiner only vaguely referenced service and made no specific mention of the Veteran’s report of his popping shoulder in 2004 when loading the back of a truck while on active duty. Therefore, this claim must be remanded, so as to include a full and complete consideration of the Veteran’s incident in 2004. The matters are REMANDED for the following action: 1. Schedule the Veteran for another VA examination with an appropriate clinician to determine the nature and etiology of his right shoulder disability. The examiner must elicit a complete history from the Veteran, which includes the 2001 fall and the 2004 shoulder pop that are noted in the Veteran’s records on file. The examiner also must provide written consideration of the complete history, as well as all statements made by the Veteran. The examiner must opine whether the current right shoulder disability is at least as likely as not related to an in-service injury, event, or disease, specifically considering the 2001 fall and the 2004 shoulder pop. A complete rationale for all opinions if required. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E.L. Aumiller, 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.