Citation Nr: 21015369 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 14-07 411 DATE: March 17, 2021 REMANDED Entitlement to service connection for a right shoulder disorder, to include as due to a service-connected cervical spine disability, is remanded. Entitlement to service connection for a left shoulder disorder, to include as due to a service-connected cervical spine disability, is remanded. REASONS FOR REMAND The Veteran served on active duty in the Navy from October to November 1985, and in the Air Force from October 1986 to August 1996 and from November 2001 to August 2003. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a May 2011 rating decision issued by a regional office (hereinafter agency of original jurisdiction or AOJ) of the Department of Veterans Affairs (VA). The Veteran testified at a July 2017 video hearing before the undersigned Veterans Law Judge, a transcript of which is attached to the record. This matter was previously remanded by the Board for further development in September 2019. 1. Entitlement to service connection for a right shoulder disorder, to include as secondary to a service-connected cervical spine disability, is remanded. 2. Entitlement to service connection for a left shoulder disorder, to include as secondary to a service-connected cervical spine disability, is remanded. The Veteran’s initial claims were for entitlement to service connection for bilateral shoulder arthritis. He had indicated that he was diagnosed with shoulder arthritis and prescribed treatment by a private physician during or shortly after his separation from service. As noted above, the Board remanded these claims to the AOJ in order to afford the Veteran a VA examination for his bilateral shoulder disorders, which occurred in December 2020. Upon examination, the VA examiner noted a 2018 left rotator cuff tear, but imaging for both shoulders was negative for arthritis. The Board notes that the Veteran claimed symptoms of pain, numbness, and weakness in both shoulders in his April 2012 notice of disagreement, and that his claims were previously reclassified as reflected above per Clemons v. Shinseki, 23 Vet. App. 1 (2009). The December 2020 VA examiner opined that the Veteran’s right shoulder disorder was less likely than not due to his active service, as a 2005 post-separation x-ray indicated a normal shoulder and there was no objective evidence of a right shoulder condition upon examination. She also opined that the Veteran’s left shoulder disorder was less likely than not related to his active service, noting both that his complaints of left shoulder pain began in 2018, approximately 16 years after his initial inservice shoulder complaints, and that both inservice and current imaging revealed a normal left shoulder. Finally, the examiner observed that the Veteran’s private treating clinician told him in January 2019 that his left shoulder pain was due to a cervical condition, specifically severe left C3-C4 and C5-C6 foraminal stenosis due to spondylosis. The Board observes that the Veteran reported symptoms of bilateral shoulder pain, numbness and weakness in April 2012, during the period on appeal. When a disability is not active at a VA examination, the current disability prong of a service connection claim is still met if the disability was active at or near the time a claim for VA disability compensation is filed or anytime during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board further observes that the Veteran is competent to report readily observable symptoms. Finally, the Board notes the Veteran currently manifests service-connected cervical spine arthritis, which, as the December 2020 VA examiner noted, a private physician has indicated may be responsible for the Veteran’s reported shoulder symptoms. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds the December 2020 medical opinion inadequate as, while the VA examiner addressed whether the Veteran’s bilateral shoulder disorders were due to his active service, she did not address whether the Veteran’s shoulder disorders were caused or aggravated by his service-connected neck disability. In this case the Board is required to address entitlement to secondary service connection as it was reasonably raised by the private medical records and VA examiner. See Robinson v. Peake, 21 Vet. App. 545 (The Board commits error...in failing to discuss a theory of entitlement that was raised either by the appellant or by the evidence of record). Therefore, remand for an additional opinion is necessary to properly adjudicate the claims. The matters are REMANDED for the following action: 1. Obtain and associate with the record all VA and relevant private treatment records for the Veteran. 2. Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran’s bilateral shoulder disorders. After reviewing the claims file, the examiner should opine: (a) Whether it is at least as likely as not (50 percent probability or greater) that any left or right shoulder disorder was caused by or results from his service-connected cervical spine disability; and (b) Whether it is at least as likely as not (50 percent probability or greater) that the service-connected cervical spine disability results in any additional functional impairment associated with his left and/or right shoulder (e.g., a medically discernible increase in frequency, duration and/or severity of limitation of motion or other functional impact, even if temporary, above the degree associated with that expected from his baseline left and right shoulders alone). The examiner must provide supporting rationale for any conclusions reached. In formulating the requested opinion, the examiner is asked to address the following: •The Veteran’s April 2012 report of numbness, weakness, pain and reduced range of motion in his shoulders bilaterally. •January 2019 private medical records in which a treating clinician informed the Veteran that his shoulder symptoms were likely the result of a cervical spine disorder revealed by contemporaneous imaging. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. C. Schumacher, 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.