Citation Nr: 21021369 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 15-39 147 DATE: April 12, 2021 ORDER Entitlement to service connection for a left shoulder disability, to include glenohumeral joint osteoarthritis, is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran’s favor, his glenohumeral joint osteoarthritis is at least as likely as not related to service. CONCLUSION OF LAW The criteria for service connection for a left shoulder disability, to include glenohumeral joint osteoarthritis, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from August 1955 to June 1959. During his period of service, he earned the Good Conduct Medal. The issue of entitlement to service connection for a left shoulder disability, to include glenohumeral joint osteoarthritis, was previously before the Board in December 2019. In that decision, the Board denied entitlement to service connection for the aforementioned disability. In a November 2020 Joint Motion for Partial Remand (Joint Motion), the United States Court of Appeals for Veterans Claims (Court) indicated that the Board failed to provide an adequate statement of reasons or bases. Specifically, the Board failed to acknowledge or address a February 2018 private medical opinion. The parties agreed that the Board’s decision finding that Veteran was not entitled to service connection for a left shoulder disability, to include glenohumeral joint osteoarthritis, should be vacated and the matter remanded to the Board for actions consistent with the Joint Motion. Entitlement to service connection for a left shoulder disability Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38U.S.C. §1110; 38C.F.R. §3.303. In order to prevail on a claim of service connection, generally, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The Veteran contends that his left shoulder disability is related to his period of active service. With respect to the first element of service connection, a current diagnosis, the Veteran’s June 2019 shoulder and arm conditions examination report notes a diagnosis of glenohumeral joint osteoarthritis. Thus, the current disability criterion for service connection is met. See Shedden, supra. Next, the Board must consider whether the Veteran sustained a disease or injury in service. The Veteran contends that his current left shoulder condition had its onset in service following an October 1958 physical assault. The Board acknowledges that the Veteran’s service treatment records do not show any in-service complaints of or treatment for a left shoulder condition; however, the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an “absolute bar” to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) (“Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms”). The Veteran testified at his February 2018 videoconference hearing that he was attacked by a corpsman who returned from liberty inebriated. He hit his shoulder on the steel deck after his attacker, whom he described as being larger in size, jumped on him. He stated that he did not notice pain during the course of fighting off his attacker but felt pain immediately thereafter. The Veteran is competent to provide statements identifying left shoulder pain at the time of the attack, as pain is capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007). Thus, resolving all doubt in favor of the Veteran, the Board finds that he has provided credible evidence identifying that he suffered a left shoulder injury in service. As such, the Veteran has satisfied the second element for service-connection. See Shedden, supra. As to the third element of service connection, it must be determined whether the Veteran’s left shoulder disability is related to service. A private medical opinion was associated with the Veteran’s claims file in March 2018. The physician indicated that she reviewed the Veteran’s statement regarding the mechanisms of injury to his left arm during his period of service. Although the physician was unable to substantiate the Veteran’s claim nor conclusively state that the described incident caused his injury, she did indicate that the mechanism of a fall to the ground and fighting on the metal deck was certainly a plausible explanation for his left shoulder trauma. Accordingly, she opined that it was as likely as any other scenario to be a cause for the Veteran’s shoulder pain. Pursuant to the July 2018 Board remand, the Veteran appeared for a VA shoulder and arm conditions examination in June 2019. The VA examiner diagnosed glenohumeral joint osteoarthritis. At the time of the examination, the Veteran reported being assaulted in Fall 1958, which resulted in injury to his left shoulder. The problems with his left shoulder have gradually progressed over the years. The VA examiner opined that the Veteran’s left shoulder disability was less likely than not incurred in or caused by service. As rationale, the VA examiner explained that available service treatment records were negative for a shoulder injury. At the time of separation, no shoulder condition was indicated. The VA examiner noted a September 1959 examination which documented an in-service left shoulder injury and diagnosed left shoulder bursitis. The VA examiner also noted an August 1959 letter from Dr. M. C. diagnosing tendonitis of the left shoulder resulting from an injury while in service. Thereafter, the next medical records concerning the shoulders were X-rays performed 2011, which showed bilateral glenohumeral degenerative changes. The VA examiner further noted that the Veteran did have an unreported in-service incident and that he did have a diagnosis of left shoulder tendonitis or bursitis after separation from service. However, there was no evidence that the Veteran’s current arthritis was related to the alleged injury and diagnosis of tendonitis or bursitis. The VA examiner attributed the Veteran’s arthritis to age-related degenerative changes. As there were no records between 1959 and 2011 indicating treatment for a shoulder condition, the examiner determined that there was insufficient evidence to relate the in-service incident to the Veteran’s current condition.   Given both positive and negative nexus opinions of seemingly equal probative value, including the private medical opinion of record linking the current left shoulder disability to service, combined with the Veteran’s testimony regarding ongoing symptoms, the Board finds that the evidence of record is at least in a state of relative equipoise. Accordingly, the benefit of the doubt will be conferred in the Veteran’s favor, and his claim for service connection for a left shoulder disability, to include glenohumeral joint osteoarthritis, is granted. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Tracy O. Joseph, 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.