Citation Nr: 21021174 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 12-30 987A DATE: April 12, 2021 ORDER 1. Entitlement to a disability rating in excess of 20 percent for injury to right shoulder, post-operative acromioplasty (right shoulder disability) is denied. 2. Entitlement to service connection for right knee disability, to include arthritis and to include as due to service-connected right shoulder disability, is denied. 3. Entitlement to service connection for left knee disability, to include arthritis and to include as due to service-connected right shoulder disability, is denied. REMANDED 4. Entitlement to service connection for a left shoulder disability is remanded. FINDINGS OF FACT 1. The right shoulder disability has not manifested with right arm limitation of motion to 25 degrees from side at any point during the appeal period. 2. Right knee disability did not have its onset during active service, was not manifested within one year of service discharge, is not otherwise related to active service, and is not caused or aggravated by the service-connected right shoulder disability. 3. Left knee disability did not have its onset during active service, was not manifested within one year of service discharge, is not otherwise related to active service, and is not caused or aggravated by the service-connected right shoulder disability. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for a right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5201. 2. The criteria for service connection for right knee disability, to include arthritis and to include as due to service-connected right shoulder disability, have not been met. 38 U.S.C. §§ 1101, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for left knee disability, to include arthritis and to include as due to service-connected right shoulder disability, have not been met. 38 U.S.C. §§ 1101, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1975 to May 1987. The Veteran provided testimony before a Veterans Law Judge in May 2015 and a hearing transcript is associated with the record. In January 2021, the Veteran was informed that the Veterans Law Judge who had conducted his Board hearing was no longer employed at the Board. The Veteran was informed that he had a right to an additional hearing before a different Veterans Law Judge and that if he did not respond within 30 days, the Board would assume that he did not want another hearing. As the 30 days to respond has expired and the Veteran has not responded to date, the Board assumes he does not want another hearing and will proceed with the appeal. This matter was previously remanded by the Board in December 2017 in order to obtain adequate VA medical opinions as to the claims for service connection and a VA examination responsive to the range of motion testing for the right shoulder as required under Correia v. McDonald, 28 Vet. App. 158 (2016). Although the Veteran’s attorney has asserted within an April 2020 brief that the May 2019 VA opinion is inadequate, for the reasons discussed further herein, the Board finds that the January 2020 VA addendum opinion is adequate, and thus there has been substantial compliance with the requested development, such that the matter is ripe for adjudication. The Board notes that prior to certification of the appeal to the Board, in a January 2020 rating decision, the RO granted service connection for left foot metatarsal stress fracture. This represents a full grant of the benefits sought and thus this issue is no longer before the Board. Increased Rating 1. Entitlement to a disability rating in excess of 20 percent for right shoulder disability. Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects the Veteran’s ability to function under the ordinary conditions of daily life, including employment, by comparing the Veteran’s symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. The provisions regarding the avoidance of pyramiding, see 38 C.F.R. § 4.14, do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare-ups. However, those provisions should only be considered in conjunction with the DCs predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Under DC 5201, limitation of motion of an arm at shoulder level warrants a 20 percent evaluation for the major extremity. Limitation of the arm midway between side and shoulder level warrants a 30 percent evaluation. When motion is limited to 25 degrees from the side, a 40 percent evaluation is appropriate for the major extremity. See 38 C.F.R. § 4.71a. As the Veteran is right-handed, this disability involves his major extremity. At the March 2015 Board hearing, the Veteran testified that he experienced increased limitation with his right arm and hand, difficulty cleaning in high place, brushing his teeth, cleaning himself, and general difficulty with reaching. He also reported increased pain, use of pain medications, and that he is unable to do a lot of lifting up over head with his right shoulder. He reported that his arm gets fatigued and becomes numb. In the February 2011 notice of disagreement, the Veteran reported that he has severe deformity with osteoarthritis and is sufficiently limited in motion, warranting a 30 percent rating or higher. The Board has carefully reviewed the evidence of record and finds the preponderance of the evidence is against an evaluation in excess of 20 percent for the right shoulder disability. The evidence shows that the Veteran’s left shoulder disability does not result in limitation of the motion of the left arm to 25 degrees or less from the side to warrant a 30 percent rating. At worst, the Veteran’s left shoulder flexion was limited to 80 degrees (90 degrees -10 degrees) and abduction to 80 degrees (90 degrees - 10 degrees), as found in the February 2009 VA examination. During that examination, the Veteran’s right shoulder flexion was limited to 130 degrees with pain beginning at 90 degrees, abduction to 130 degrees with pain beginning at 90 degrees, internal rotation to 40 degrees, and external rotation to 40 degrees. The examiner found the Veteran had additional limitations in his range of motion in 10 degrees in the shoulder following repetitive-use testing, such as pain, fatigue, lack of endurance, and pain has the major functional impact. There was no localized tenderness or pain on palpation. A June 2013 VA treatment record noted full active range of motion throughout the bilateral upper extremities and lower extremities with strength 4+/5 throughout right upper extremity. Sensation was intact to soft touch throughout bilateral upper extremities. In June 2016, the Veteran was provided with an additional VA examination. During that examination, the Veteran’s right shoulder flexion was limited to 135 degrees, abduction to 135 degrees, internal rotation to 90 degrees, and external rotation to 60 degrees. There was painful motion noted at 120 degrees on terminal elevation. The examiner found the Veteran did not have additional limitations in his range of motion in the shoulder following repetitive-use testing. There was no pain on weight bearing, localized tenderness or pain on palpation, or crepitation. There was no flare-up noted. The Veteran did not have ankylosis. The Veteran had positive results for the Hawkins’ Impingement Test on the right side, but had a negative result on the Empty-can Test, External Rotation/ Infraspinatus Strength Test, and the Lift-off Subscapularis Test. The examiner noted that the Veteran lost elevation and has pain on elevation on the right shoulder and that the Veteran stopped working in 2012 after 15 years in janitorial services due to his shoulders. The Veteran was provided with another VA examination in May 2019. The Veteran’s left shoulder flexion was limited to 140 degrees, abduction to 100 degrees, internal rotation to 70 degrees, and external rotation to 40 degrees. There was difficulty with overhead motion in flexion, abduction, external rotation, and internal rotation. The examiner found the Veteran did not have additional limitations in his range of motion in the shoulder following repetitive-use testing. There was no pain on weight bearing, localized tenderness or pain on palpation, or crepitation. The Veteran reported flare-ups that resulted in increase in severity of bilateral shoulder pain with sleeping. The examiner noted the Veteran was being examined during a flare-up, but pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups. There was no pain on passive range of motion testing or evidence of pain when the joint is used in non-weight bearing. The examiner documented the Veteran did not have ankylosis. The Board has considered the Veteran’s lay statements of record, which are probative evidence insofar as they report observable symptomatology; however, to the extent that the Veteran asserts that his right shoulder disability is worse than shown by the objective medical evidence of record, the Board finds that the clinical findings by a medical professional are more probative as to the severity of the disability, particularly when the examiner provided detailed clinical findings as to range of motion, functional loss, and muscle strength. In order to warrant an increased disability rating in excess of 20 percent for his right shoulder disability, the Veteran would need to display limitation of motion of the arm to 25 degrees or less from the side. Significantly, however, the preponderance of the evidence is against the Veteran’s right shoulder disability manifesting to 25 degrees or less from the side. As such, an increased disability rating is not warranted under DC 5201. The Board has considered the effects of the Veteran’s symptoms, including pain and functional loss, and the Board concludes that the preponderance of the evidence is against a finding of limitation of the motion of the right arm to 25 degrees or less from the side, which is the criteria needed for a 30 percent rating. The examination results show that the Veteran had full (5/5) muscle strength in his right shoulder at the June 2016 and December 2019 VA examinations, and 4+/5 muscle strength in the June 2013 VA treatment record. Strength that is full is evidence against weakness, and strength rated 4/5 is evidence of some weakness, but the Board finds that the 20 percent rating contemplates the weakness the Veteran has in the right upper extremity. Taking into account the evidence of record indicating the Veteran’s regular complaints of pain and other findings of functional loss, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s pain and functional limitations resulted in limitation of the motion of the right arm to 25 degrees or less from the side, which would be required for a finding that the Veteran was entitled to a 30 percent disability rating. The 20 percent rating contemplates, at a minimum, moderate functional impairment. Thus, a higher rating under the provisions of 38 C.F.R. §§ 4.40 and 4.45 is not approximated in the Veteran’s disability picture for this appeal period. The Board also acknowledges the Veteran’s report of numbness and deformity in his right arm and that he has attributed the symptoms to his service-connected right shoulder disability. However, the evidence supports that the Veteran’s symptoms of numbness, tingling, and or pain are attributed to his non-service-connected cervical spine disability as discussed in June 2015 VA treatment record, and there are no findings of deformities in high upper right extremity. Thus, the Veteran does not have a separate diagnosis of symptoms of numbness as attributable to his right shoulder disability. The Veteran is not competent to state that his numbness in the upper right extremity is related to his service-connected right shoulder disability. The issue is medically complex, as it requires specialized medical education. Consequently, the Board gives more probative weight to the conclusions made by competent professionals. The Board has also considered the potential applicability of DCs 5200-5203, which contemplate additional disabilities of the shoulder and arm. See 38 C.F.R. § 4.71a, DCs 5200-5203. DC 5200 provides rating criteria for ankylosis of scapulohumeral articulation, where the scapula and humerus move as one piece; DC 5202 provides rating criteria regarding impairment of the humerus; and DC 5203 provides rating criteria regarding impairment of the clavicle or scapula. The objective evidence of record, including as discussed above, does not support any form of ankylosis of scapulohumeral articulation, impairment of the humerus, and the Veteran’s impairment of the clavicle is not manifested by nonunion, malunion, or dislocation of the clavicle or scapula; as such, the application of DCs 5200-5203 is not warranted. In sum, the preponderance of the evidence is against a disability rating in excess of 20 percent for the Veteran’s right shoulder disability is warranted. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran’s claim for an increased rating is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Service Connection 2. Entitlement to service connection for right knee disability. 3. Entitlement to service connection for left knee disability. At the May 2015 Board hearing, the Veteran testified that his knees started bothering him during service after breaking his left foot and doing training. He claims the wear and tear from the injury and training exacerbated his knees and made his knees sore. He reported running every day for 12 years for training runs from 3 to 20 miles. He reported that he complained of knee problems in service. He reportedly was given ice and told not to run, and he continued to have knee problems post-service. A February 23, 1975 Report of Medical History questionnaire reflects the Veteran denied ever having or having then a history of arthritis and bone or joint deformity, and shoulder pain. However, the Veteran’s response to a history of trick or locked knee is not legibile. A March 1975 service treatment record (STR) notes the Veteran reported his “right leg hurts,” and there was no tenderness, enema, swelling. He was diagnosed with a muscle pull. A June 1976 STR noted a right patella accident to knee one day ago by shutting a door on it. The Veteran reported pain on the patella. The impression was contusion to the right knee and ace wrap was prescribed. An April 1987 separation physical examination was normal as to the lower extremities. The Veteran denied current medical problems or medications, hospitalization, or significant illness. A November 1980 reenlistment examination was normal as to the lower extremities, and only discussed right shoulder injury and surgery. An August 1987 VA orthopedic examination report notes no complaints related to the knees. The Veteran reported a right shoulder, left ankle, and hamstring injury, but did not report symptoms or injuries related to the knees. A June 1993 private treatment record notes the Veteran stepped into a gap on concrete floor at the airport where he worked as a supervisor and twisted his right knee. A January 2004 private treatment record shows the Veteran reported bilateral knee pain and the physician documented that the Veteran had right knee arthroscopy in 1993. The physician concluded right knee pain was likely secondary to recurrent medial meniscal tear and early onset arthritis of right knee and left knee pain is likely secondary to meniscal tear. A February 2004 private treatment record shows mild arthritic changes in the right and left knees after magnetic resonance imaging (MRI) scans looking for tears. The left knee had intact meniscus and ligaments, small joint effusion, no definitive tear, a little more prominence of arthritis by MRI scan than on standing x-ray. Right knee MRI showed prior surgery with three compartment arthritis changes, advanced mostly in the patellofemoral compartment. The Veteran filed his claim for service connection for right and left knee disabilities in January 2009. In a July 2009, review of systems, the Veteran reported joint pain or swelling, limitation in range of motion, and knee pain. Physical examination of the right and left legs was normal. In an August 2009 VA examination, the Veteran reported his right knee condition existed since June 1976 involving a door closing on it. The examiner provided a diagnosis of right knee degenerative arthritis, including the patella joints. In a December 2009 VA examination report, the Veteran reported being diagnosed with osteoarthritis and that the condition has existed since 1976 due to combat training. In the opinion issued in January 2010. The examiner opined it is less than likely that the Veteran’s right knee condition is related to service-connected right knee incident. The examiner explained that review of medical records dated in 1976 show that the Veteran suffered a right patella contusion, otherwise known as a bruise. The examiner pointed out that at present time, the Veteran’s knee is status-post arthroscopic repair for meniscal tear with resultant degenerative changes of the knee and meniscus abnormality and that there is no medical explanation to associate the two conditions and one did not cause the other. The examiner concluded it is a new and separate condition noted on current exam and at present time, the anterior aspect of the right knee where the contusion took place is without pathology and thus the examiner was unable to state a relationship between the two conditions without resorting to speculation. An October 2009 private treatment record shows moderate osteoarthritis of the right and left knees. In the February 2011 NOD, the Veteran reported that he was treated for trauma to the knee and in 1990, he required surgery to repair the damage caused by years of daily training and that trauma. He continues to receive treatment and claims service connection should be granted on a presumptive basis for a chronic disease. In a June 2016 VA examination, the examiner provided a negative nexus opinion, the Veteran reported that he did not have specific knee problems in service, but he reported swelling sometimes in his knees due to running. The examiner noted that on leaving service, the Veteran worked in active occupations for over 20 years and it was in the late 1990s that his knees began to act up that led to total knee replacement on the right knee in 2013. The examiner noted the Veteran had left knee degenerative joint disease consistent with age 58. Regarding service connection on a secondary basis, the examiner opined it is less likely than not that his bilateral knee condition is due to the Veteran’s service-connected right shoulder condition because the right shoulder has elevation to 135 degrees with pain at 120 degrees and that this joint is functional although he has difficulty using it above shoulder level, the examiner explained that such would not impose excess strain on any other joint. A May 2017 private treatment record reflects the Veteran had a diagnosis of degenerative joint disease, and he underwent left knee total knee arthroplasty. In a May 2019 VA examination report, the examiner noted no STR evidence for chronic complaints to suggest secondary service connection for knee or shoulder conditions and there are no STR evidence for ongoing knee or shoulder complaints to suggest permanent aggravation. In a January 2020 VA addendum opinion, the VA physician explained that the documented post-service joint complaints are all outside the window of chronic complaints occurring withing one year following discharge and, as such, are likely due to wear and tear over time and not to in-service injuries. The Board has carefully reviewed the evidence of record and finds the preponderance of the evidence is against the grant of service connection for right and left knee disabilities. The reasons follow. Regarding evidence of a current disability, the evidence shows a diagnosis of bilateral knee osteoarthritis, status post bilateral arthroplasty, as confirmed in the June 2016 VA examination report. Thus, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, as indicated above, the June 1976 STR noted a right patella accident by shutting a door on it and the impression was contusion to the right knee. A September 1977 STR physical determined the Veteran was physically qualified. An April 1987 separation physical examination showed a normal clinical evaluation of the lower extremities. The Veteran denied current medical problems or medications, hospitalization, or significant illness. A November 1980 reenlistment examination was normal as to the lower extremities, and only discussed right shoulder injury and surgery. The Board notes that an illegible examination appears normal, as there is a line is going through “normal” boxes except number 34, “GU system.” Given the above, the Board acknowledges that STR document a single report of right knee pain and/or injury, and as such, the in-service element of the Veteran’s direct service connection claim is also met as to the right knee only. The Veteran reports that he experienced continued bilateral knee symptoms due to rigorous running during service, however, the normal clinical evaluations of the lower extremities are evidence that refutes the Veteran’s allegation of continuous chronic bilateral knee symptoms as a result of his duties in service. While an in-service disease or injury is shown in the service treatment records as to the right knee only, there is no probative evidence that arthritis of the right and left knees manifested during active service or within one year of the Veteran’s service discharge so as to warrant a grant of presumptive service connection for arthritis as a chronic disease. The first showing of a right knee problem was in 1993 when the Veteran had right knee arthroscopy, which appears to be related to a 1993 work injury. In addition, degenerative changes in the right and left knees was not noted until 2004, which is more than 17 years following service discharge. Additionally, as to evidence of a nexus between the diagnosis of bilateral knee disabilities and service, the Board finds the preponderance of the evidence is against a nexus. Here, the Board finds the June 2016, May 2019, and January 2020 VA opinions and addendum opinions, when taken as a whole, are highly probative, as the examiners had reviewed the evidence and provided conclusions that were based upon the evidence and medical principles. The opinions support the finding that the current bilateral knee disability is not related to service and is not caused or aggravated by the service-connected right shoulder disability. This is evidence against a nexus between the current bilateral knee disabilities and service and a service-connected disability. At the present time, there is no competent evidence to weigh against the VA opinions. Thus, to the extent that the Veteran alleges having experienced knee symptoms continuously since service, the Board finds that such allegations are not credible given the passage of many years between discharge from active service and the medical documentation of a claimed disability. Notably, the August 1987 VA orthopedic VA examination report notes no complaints related to the knees. The Veteran reported right shoulder, left ankle, and hamstring injuries, but did not report any symptoms or injuries related to the knees. The Board finds it reasonable to conclude that if the Veteran was experiencing ongoing bilateral knee pain at that time, he would have reported it, as he had the wherewithal to report other joint symptoms, such as the right shoulder and left ankle symptoms. His silence as to the knees is evidence against a finding that he was experiencing ongoing knee symptoms as he was being discharged from service. Further supporting this finding is a June 1993 private treatment record, which shows the Veteran stepped into a gap on concrete floor and twisted his right knee at the airport where he worked as a supervisor. At that time, he attributed the onset of his right knee pain to the work-related injury. In a January 2004 VA treatment record, the Veteran reported that he underwent right knee arthroscopy in 1993. With no evidence of chronic knee disabilities in the STRs and the Veteran’s report that he injured his right knee in 1993 followed by surgery, six years between service and the 1993 private treatment record, the VA physicians opined that the medical conditions that were identified would be new conditions that arose in the intervening years of civilian life, that is well outside of one-year, post-service period. The June 2016 VA physician also pointed out that the Veteran himself indicated that his knee problems began in the 1990s. The VA physician also documented that the Veteran’s osteoarthritis was consistent with his age. Regarding service connection on a secondary basis, the June 2016 VA examiner also explained that the service-connected right shoulder has elevation to 135 degrees with pain at 120 degrees and that this joint is functional, and although he has difficulty using it above shoulder level, the examiner explained that such would not impose excess strain on any other joint. The VA opinions are considered probative, as they were definitive, based upon a complete review of the Veteran’s entire claims file, and supported by a thorough rationale. Consequently, the Board gives more probative weight to the VA opinions. While the Veteran is competent to report symptoms that he has experienced in service and since service, he is not competent to directly link the current bilateral knee disabilities to service or a service-connected disability, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. For all the reasons laid out above, the Board finds that the preponderance of the evidence is against the claims for service connection for right and left knee disabilities, to include as due to service-connected right shoulder disability. Thus, as the preponderance of the evidence is against the claims, there is no reasonable doubt to be resolved, and the claims for service connection is denied. 38 U.S.C. § 5107(b). REASONS FOR REMAND 4. Entitlement to service connection for left shoulder disability. In the December 2017 remand, the Board requested an addendum VA opinion to comment on the Veteran’s continuous complaints of left shoulder pain, as noted on a July 1988 orthopedic examination, as well as treatment reports dated in 2002 and 2004, as well as the Veteran’s other contentions. In a May 2019 VA addendum opinion, the VA examiner opined that the conditions of the left shoulder is less likely as not directly service related, as STRs do not document repetitive injuries or chronic complaints of either of these joints. The RO requested an additional VA opinion in light of the above inadequate opinion that was provided in January 2020. The VA physician explained the documented post service joint complaints are all outside the window of chronic complaints occurring within one year following discharge and, as such, are likely due to wear and tear over time and not to in-service injuries. Regarding pain with shoulder ROM, pain occurred at the end of the ranges of motion as documented in the STRs. However, the Board finds the Board directives were not followed with substantial compliance by the examiner. See Stegall v. West, 11 Vet. App. 268 (1998). Here, in a June 1987 VA examination report, the Veteran reported left shoulder pain. An August 1987 x-ray noted acromioclavicular joints bilaterally with and without weights were normal, however, upon orthopedic examination, the clinician did not address the Veteran’s report of left shoulder pain at that time. Thus, contrary to the VA physician who authored the May 2019 and January 2020 VA addendum opinions, the Veteran, in fact, reported left shoulder pain one month after discharge, which is well within one year of discharge. Therefore, the Board finds that a remand is necessary for an addendum opinion, which specifically addresses the medical history as well as the Veteran’s lay contentions, to include his contention that the February 2002 post-service injury further aggravated his left shoulder condition, as requested. The matter is REMANDED for the following action: Refer the Veteran’s file to an appropriate examiner for a medical opinion regarding the etiology of the left shoulder disability. The examiner is asked to review the record. If the examiner finds that an in-person physical examination is necessary, an examination should be scheduled and any indicated evaluations, studies, and tests deemed to be necessary by the examiner should be performed. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, where applicable: • The Veteran served on active duty from February 1975 to May 1987. • The Veteran contends that he injured his left shoulder at the same time he injured his right shoulder (the right shoulder is service connected) while taking boxes off a truck and catching an item that weighed 800 pounds as it fell off the forklift. The documented injury occurred in December 1986. See VBMS entry with document type, “STR – Medical,” receipt date 10/21/1976, with “#2” written in the subject field, on page 25. • An April 1987 separation Report of Medical Examination shows that clinical evaluation of the upper extremities was normal. On the second page of that document, the Veteran denied current medical problem or medications, hospitalization, significant illness, or injury since last physical examination in 1980 and only discusses right shoulder injury and surgery. See VBMS entry with document type, “STR – Medical,” receipt date 10/21/1976, with “#2” written in the subject field, on pages 11-12. • An August 1987 VA x-ray of both acromioclavicular joints with and without weights were both normal. See VBMS entry with document type, “VA Examination,” receipt date 06/30/1987. • In the July 1988 Orthopedic Examination, the Veteran reported that in November 1986 that when some boxes fell, he caught them, which pulled his shoulder down and that he was unsure of the diagnosis he was given but that he was treated for his right shoulder with arthroscopy. He reported that his left shoulder may need arthroscopy. The diagnosis was status post bilateral shoulder injury with residual pain and decrease in range of motion. X-rays taken at that time were normal. See VBMS entry with document type, “VA Examination,” receipt date 07/21/1988, on page 1-2. • In the February 1991 VA examination, the Veteran reported that he injured his “shoulders” while loading 800-pound boxes into the back of a truck, and the box fell, jerking his shoulders. The examiner provided clinical findings of the right shoulder only. See VBMS entry with document type, “VA examination,” receipt date 02/22/1991, with “#1” written in the subject field. • A February 2002 private treatment notes the Veteran reported injuring both shoulders at Camp Lejeune in 1987 and had subsequent surgery on his right shoulder. He did not have any surgery on the left shoulder. He again reported that in 1987, he tried to catch an 800-pound box and injured both shoulders. The physician concluded he had arthroscopic debridement on the right and the impression was subacromial impingement possibly in the setting of rotator cuff tendinopathy, lateral epicondylitis, repetitive strain injury with work activities. See VBMS entry with document type, “Medical Treatment Record - Non-Government Facility,” receipt date 05/24/2011, on page 10. • A May 2002 private treatment record noted left shoulder pre-op diagnosis of left shoulder adhesive capsulitis, left shoulder subacromial impingement, and shoulder pain and weakness. The surgery included extensive debridement and release of the glenohumeral joint and lysis of adhesions. Subacromial decompression and extensive lysis of adhesions in the subacromial space, insertion of transcutaneous catheter for continuous infusion. See VBMS entry with document type, “Medical Treatment Record - Non-Government Facility,” receipt date 05/24/2011, on page 7. • A March 2004 Functional Capacity Evaluation noted the Veteran injured his right shoulder in February 2002 and that he was employed as a service runner for 8 years and at the time that he sustained his injury to the left shoulder when throwing a paper out the window and had pain in his left shoulder. See VBMS entry with document type, “Medical Treatment Records - Furnished by SSA,” receipt date 04/10/2014, on pages 54-55. • A July 2012 Residual Functional Capacity Questionnaire shows that the Veteran was treated by the physician since 2011 for shoulder pain, as well as other complaints. The physician indicated that the Veteran’s restrictions and limitations to include as a result of the shoulder started in 1987. See VBMS entry with document type, “Medical Treatment Records - Furnished by SSA,” receipt date 04/10/2014, on pages 49-51. • The Veteran underwent a VA examination in February 2009. The Veteran reported that he injured his left shoulder while moving boxes. The left shoulder had tenderness and guarding of movement, but no signs of edema, effusion, weakness, redness, and heat. See VBMS entry with document type, “VA examination,” receipt date 02/24/2009. • The Veteran underwent an additional VA examination in June 2016. The Veteran reported that he injured his left shoulder at the same time he injured his right shoulder. See VBMS entry with document type, “C&P Exam,” receipt date 06/24/2016, with “#3” written in the subject field. • The examiner provided a negative nexus opinion stating that there are multiple entries on the right shoulder but no references to the left shoulder, and in a separation examination dated October 2, 1987 (note that the correct date of the examination is April 1987), the Veteran marked “No” to all musculoskeletal questions. However, there was a specific mention of the right shoulder but nothing on the left, and exam revealed near normal exam of the left shoulder with mild findings of DJD on x-rays consistent with age 58. See VBMS entry with document type, “C&P Exam,” receipt date 06/24/2016, with “#4” written in the subject field. • A May 2019 VA examination report shows diagnosis of bilateral shoulder impingement syndrome and the Veteran reported onset of bilateral shoulder pain to strain injuries sustained when he caught boxes being loaded for shipment in 1987. In 1987 he underwent unspecified arthroscopic surgery to the right shoulder and unspecified arthroscopic surgery to the left shoulder following discharge, but he could not recall the year. The examiner opined that the conditions of the left shoulder are less likely as not directly service related as STRs do not document repetitive injuries or chronic complaints of either of these joints. See VBMS entry with document type, “C&P Exam,” receipt date 05/14/2019, with “#1” written in the subject field, on page 1. • A January 2020 VA addendum opinion stated the documented post service joint complaints are all outside the window of chronic complaints occurring within one year following discharge and, as such, are likely due to wear and tear over time and not to in service injuries. Regarding pain with shoulder ROM, pain occurred at the end of the ranges of motion as documented in the STRs. However, as noted above, the Veteran reported left shoulder pain in June 1987, one month after discharge from service. See VBMS entry with document type, “C&P Exam,” receipt date 01/09/2020, with “#1” written in the subject field. • The examiner’s review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. The examiner is asked to answer the following questions based upon the evidence of record and sound medical principles: Is the any diagnosed left shoulder disability at least as likely as not (50 percent or greater likelihood) caused by or a result of service from February 1975 to May 1987? Please specifically discuss the Veteran’s lay contentions that his left shoulder pains started in service and were caused by the December 1986 injury while moving boxes during service (locations above) and that the February 2002 post-service work injury further aggravated his left shoulder condition. Please explain your answers by citing to supporting clinical data and/or medical literature, as deemed appropriate. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sarah Campbell, 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.