Citation Nr: 21022112 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 19-22 503A DATE: April 14, 2021 REMANDED Entitlement to service connection for right shoulder degenerative joint disease with tendinopathy is remanded. Entitlement to service connection for left shoulder rotator cuff tendinopathy is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1969 to September 1973. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at an April 2021 videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has not yet been associated with the file. The Board notes this is of no prejudice to the appellant as the Board is remanding the appeal for further development, and a copy of the hearing transcript will be associated with the claims file in the ordinary course of business. 1. Entitlement to service connection for right shoulder degenerative joint disease with tendinopathy 2. Entitlement to service connection for left shoulder rotator cuff tendinopathy The Veteran contends that his right and left shoulder disabilities are secondary to his service-connected diabetes mellitus and diabetic peripheral neuropathy of the sciatic and femoral nerves of the lower extremities. See generally August 2019 Correspondence. The Veteran was afforded a VA shoulder examination in July 2018 and diagnoses of right shoulder degenerative joint disease, tendon tears and tendinopathy, and left shoulder rotator cuff tendinopathy were made. The Veteran reported that his bilateral shoulder injuries were due to falls caused by his service-connected bilateral lower extremity sciatic and femoral nerve diabetic neuropathy. The examiner, noting the Veteran “likely has more than one shoulder condition in each shoulder,” remarked that complete / comprehensive private treatment records were not available review and so the etiology of his bilateral shoulder injuries was not fully evident. The examiner concluded that a specific etiology for the Veteran’s falls could not be determined without resorting to mere speculation, when also considering non-service-connected disabilities that also affect gait and balance. The Board notes that an examiner’s report that an opinion could not be provided without resort to mere speculation is inadequate unless the examiner provides a rationale for that statement. The Board finds the examination to be inadequate. The mere absence of treatment records should not be the sole basis for a negative opinion. See Dalton v. Nicholson, 21 Vet. App. 23, 40 (2007). Here, the July 2018 examiner states that an opinion would be speculative without reviewing the Veteran’s relevant private treatment records. The record reveals that private medical treatment records were associated to the record after the July 2018 VA examination. While the Board regrets the delay, these issues are remanded to obtain a VA examination and opinion addressing the nature and etiology of the Veteran’s bilateral shoulder disabilities. Additionally, in October 2019 the Veteran indicated that he continues to receive treatment, to include from medical providers such as Kaiser Permanente and the VA Medical Centers (VAMCs) in Portland, Oregon. The Veteran has also received treatment from the VAMC in Vancouver, Washington. The Veteran’s outstanding, relevant VA and non-VA treatment reports should be obtained. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142(s) for relevant treatment provided by his private medical providers, to include Kaiser Permanente. Make two requests for the identified authorized records, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records, to include treatment reports from the VAMCs in Portland and Vancouver, for the period from August 2019 to the present. 3. Schedule the Veteran for a VA examination with an appropriate clinician to obtain a medical opinion which addresses the nature and etiology of the Veteran’s bilateral shoulder disorders. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner must review the entire claims file, to include a copy of this Remand, in conjunction with authoring the opinion. For every distinct shoulder disorder found, the examiner is asked to address whether it is at least as likely as not (a 50 percent or greater probability) that the shoulder disorder is proximately due to or is aggravated by the Veteran’s service-connected bilateral lower extremity sciatic and femoral nerve diabetic peripheral neuropathy, to include as due to falls caused by bilateral sciatic and femoral nerve diabetic peripheral neuropathy. The term “aggravation” in the above context refers to any incremental increase in disability - any additional impairment of earning capacity -in non-service-connected disabilities resulting from service-connected conditions regardless of its permanence. A complete rationale for any opinion expressed must be provided. An examiner’s report that he or she cannot provide an opinion without resort to speculation is inadequate. If it is not possible to provide a specific measurement, or an opinion without report to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Battaile 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.