Citation Nr: 21014722 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 18-02 947 DATE: March 15, 2021 REMANDED Entitlement to service connection for right shoulder disability is remanded. REASONS FOR REMAND This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2020, the Board remanded the claim to obtain a new examination and opinion with complete rationale regarding his shoulder disabilities. In an October 2020 Decision Review Office decision, the Veteran was granted service connection for his left should disability. Therefore, such claim is no longer in appellate review. Entitlement to service connection for right shoulder disability. The Veteran contends that his right shoulder disability is related to service. Alternatively, he contends that his right shoulder disability is secondary to his service-connected lumbar spine and left shoulder disabilities. See January 2021 Appellate Brief. He contends that his right shoulder disability began while on active duty and symptoms continued since service. See April 2020 Hearing Transcript. A September 2020 VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that there are no records of an in-service right shoulder complaint and it was normal on exit exam and therefore, all diagnosed right shoulder conditions are less likely than not due to service. The examiner further opined that the claimed condition is less likely than not proximately due to or the result of the Veteran’s service-connected degenerative arthritis of the lumbar spine, since there is no connection between the lumbar spine and the shoulders, and no right shoulder condition found in records. Additionally, the examiner opined that the right shoulder is less likely as not aggravated beyond its natural progression by service-connected lumbar spine condition. The Board sincerely regrets the further delay but finds that a remand is necessary in this appeal to afford the Veteran full consideration of his claim. The September VA opinion is inadequate because it relies too heavily on the lack of in-service documentation of complaints for right shoulder disability. The Veteran testified that both shoulders exhibited pain during service due to his work duties, which included digging. However, the examiner only considers complaints, or lack thereof, documented within the service treatment records and uses this limited rationale as the basis for the conclusions on direct service connection. Additionally, although the opinion addresses secondary service connection regarding disabilities that were service-connected at the date of examination, the Veteran has since become service-connected for his left shoulder condition. Based on the above, the Board finds that new direct opinion is needed to provide a rationale that addresses his credible testimony and a new secondary opinion is needed to address the now service-connected left shoulder disability. The matter is REMANDED for the following action: 1. Obtain updated VA treatment records. 2. After completing directive #1, request a supplemental medical opinion from an appropriate clinician to determine the nature and etiology of right shoulder disability. Another examination should be undertaken, if deemed necessary. The examiner should review the claims file, then opine on the following: Is it at least as likely as not (50 percent or greater probability) that the Veteran’s right shoulder disability is caused by or incurred in his service? Is it at least as likely as not (50 percent or greater probability) that the Veteran’s right shoulder disability is aggravated beyond its natural progression by his service-connected left shoulder disability? Is it at least as likely as not (50 percent or greater probability) that the Veteran’s right shoulder disability is proximately due to or the result of his service-connected left shoulder disability? The examiner should address the reports of in-service right shoulder pain and reports of laborious digging during service. A complete rationale should be provided. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Wilson, 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.