Citation Nr: 21014481 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 16-13 094 DATE: March 12, 2021 REMANDED Entitlement to service connection for a left shoulder disability, including as due to a cervical spine disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1978 to April 1984 and from April 1986 to November 2001. This appeal to the Board of Veterans’ Appeals (Board) is from an October 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2019, the Board remanded this claim back to the local RO (Agency of Original Jurisdiction (AOJ)) for further development – including especially to obtain all outstanding treatment records relevant to this claim (whether from VA and/or private providers) and then for an addendum opinion concerning whether this claimed left shoulder disability is related or attributable to the Veteran’s service, either directly due to his service or alternatively secondary to (meaning caused or aggravated by) his service-connected cervical spine disability. Unfortunately, however, still more medical comment is needed before deciding the appeal of this claim. Entitlement to service connection for a left shoulder disability, including as due to a cervical spine disability The primary basis of the Veteran’s claim is that his left shoulder disability is secondary to, meaning caused or aggravated by, a service-connected disability – namely, by the chronic pain and structural damage attributable to his already service-connected cervical spine disability (degenerative joint and disc disease). 38 C.F.R. § 3.310(a) and (b); see also Allen v. Brown, 7 Vet. App. 439 (1995). Establishing service connection on a secondary basis requires evidence showing: (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Id. There is no disputing the Veteran has left shoulder impingement syndrome (SIS), as it was diagnosed during his February 2016 VA shoulder examination. But, to warrant the granting of service connection, there also must be attribution of this left shoulder disability to his military service, either, as mentioned, by showing it is directly attributable to his service or alternatively secondarily related – again, meaning caused or aggravated by his service-connected cervical spine disability. The RO already has considered two VA medical opinions addressing this notion of secondary service connection. But the initial February 2016 opinion failed to consider whether there is aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (holding that medical opinions addressing the issue of secondary service connection are inadequate when they fail to adequately encompass the question of aggravation).   That deficiency is partly why the Board remanded this claim in January 2019, but even the additional VA medical opinion since obtained in December 2019 is insufficient. This additional opinion again found no correlation (“nexus”) between the left shoulder disability and service-connected cervical spine disability. But, in coming to that conclusion, the examiner failed to address the Veteran’s SIS in the context of his specific claim and medical history. The examiner’s opinion reproduced part of a medical article describing SIS, labeled it “Etiology,” and then concluded that cervical DDD is unlikely to aggravate SIS, “which is a distinct separate entity with different etiology.” The examiner did not discuss how or why this applies to this Veteran’s claim, also apparently did not consider that his cervical spine disability is comprised of both degenerative joint disease (DJD), i.e., arthritis, and degenerative disc disease (DDD). The Board further observes that the medical article cited asserts that SIS “implies a spectrum of clinical findings, not an injury to a specific structure.” This statement tends to undermine the examiner’s assertion that the Veteran’s cervical DDD is a “separate entity,” where SIS does not require a specific structure or injury for diagnosis. The article cited notes that risk factors for SIS include repetitive activity, overhead work activities, and athletics. This is consistent with the Veteran’s assertion that his left shoulder was aggravated by lifting and carrying ammunition boxes while in the service. The Board consequently finds this most recent medical opinion conclusory and inadequate, so still more medical comment is needed. See Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (holding that "a mere conclusion by a medical doctor is insufficient for the Board to make an informed decision as to what weight to assign to the doctor's opinion"); El-Amin, 26 Vet. App. 136 (2013). See also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (Once VA endeavors to provide an examination to obtain a medical opinion, even if not statutorily obligated to, it must provide an adequate examination and opinion, else, notify the claimant why they cannot or will not be provided).   Accordingly, this claim is again REMANDED for the following still additional development and consideration: Obtain still more medical comment (i.e., another addendum opinion) regarding the etiology of the Veteran’s left shoulder disability, including his SIS. The claims file, including a complete copy of this remand, must be made available to and reviewed by the examiner to assist in providing the specific information that is needed. To wit, the examiner is specifically asked to indicate: (a.) Whether it is at least as likely as not (50 percent or greater possibility) that any currently diagnosed left shoulder disability, including SIS, is directly related to the Veteran’s service – including to the type of physical or strenuous activity he cites as a possible source or cause of this now claimed disability (e.g., lifting and carrying ammunition boxes). (b.) Alternatively, whether it is at least as likely as not (50 percent or greater possibility) that any currently diagnosed left shoulder disability, including SIS, is secondarily related to his service, meaning was caused OR aggravated by his service-connected cervical spine disability (DJD and DDD). *If, as the prior December 2019 VA examiner concluded, DDD and SIS are separate and distinct disabilities having separate etiologies, there still must be more explanation of why the Veteran’s   service-connected cervical spine disability (DJD and DDD) is not aggravating his left shoulder disability (SIS), even if not causing it. KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board W. Stearns, 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.