Citation Nr: 21022618 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 11-13 359 DATE: April 16, 2021 ORDER Entitlement to service connection for a left shoulder disorder, diagnosed as bicipital tendonitis and arthritis, to include as secondary to service-connected bilateral pes planus and service-connected right shoulder degenerative arthritis, is granted. FINDING OF FACT Resolving reasonable doubt in his favor, the Veteran’s left shoulder disorder was caused by service or his service-connected disability. CONCLUSION OF LAW The criteria for service connection for left knee disorder, diagnosed as bicipital tendonitis and arthritis, have been met. 38 U.S.C. §§ 1101, 1110, 5100, 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1984 to November 1985. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a July 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Fort Harrison, Montana. In April 2014, the Veteran testified via videoconference at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran’s claims file. This claim was previously before the Board in July 2019, at which time it was remanded for additional development. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, to establish service connection for a disability resulting from a disease or injury incurred in service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Entitlement to service connection for a left shoulder disorder, to include as secondary to service-connected bilateral pes planus and service-connected right shoulder degenerative arthritis Pursuant to the July 2020 Board remand, the Veteran received a VA examination in November 2020 and the examiner noted a diagnosis of bilateral bicipital tendonitis. The Veteran indicated that his left shoulder condition began during active duty due to compensating for a right shoulder injury during basic training in 1984. Based on the results of the examination, the examiner concluded that the left shoulder condition was less likely than not caused or aggravated by the service-connected pes planus or right shoulder degenerative arthritis. He could not find any anatomic or pathologic connection between pes planus and the left shoulder condition. The Veteran had mild degenerative joint disease bilaterally in 2010 which could “just as easily be age appropriate in a then 59 year old woman.” Furthermore, those findings of mild degenerative joint disease in the left shoulder was not confirmed in a 2012 x-ray. There was no record of associated shoulder treatments in the 35 years since separation to connect why the contralateral left shoulder would have mild degenerative joint disease because, simultaneously, the right shoulder also had mild degenerative joint disease 25 years after separation without some form of severe trauma to either effected shoulder. At the outset, the Board finds the November 2020 VA examiner’s opinion to be of diminished probative value. A medical opinion based solely on the absence of documentation in the record is inadequate, and a medical opinion is also considered inadequate if it does not take into account the Veteran’s reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). Furthermore, the Board acknowledges that the November 2020 VA examiner opined that the Veteran’s left shoulder disability is not related to military service or a service-connected disability. The VA examiner’s conclusion is a medical conclusion that the Board cannot ignore or disregard. See Willis v. Derwinski, 1 Vet. App. 66 (1991). However, the Board is free to assess medical evidence and is not compelled to accept a medical opinion. Wilson v. Derwinski, 2 Vet. App. 614 (1992). Reading the evidence in a light most favorable to the Veteran, the Board finds that service connection for a left shoulder disability is warranted. The examiner hinges his opinion on the lack of associated shoulder treatments in the 35 years since the Veteran separated from service. There was no evidence of severe trauma to either shoulder, but the examiner notes that the Veteran is currently service connected for a right shoulder disability. In essence, the examiner concedes that a lack of evidence of severe trauma is not fatal to a claim for service connection. Furthermore, the examiner indicates that the shoulder condition “could just as easily be age appropriate in a then-59 year old woman,” a reasonable interpretation of which is that it is just as easily related to service or service-connected disability. The examiner, essentially, has placed the evidence in equipoise with regards to the cause of the Veteran’s left shoulder disability. Therefore, resolving reasonable doubt in the Veteran’s favor, the Board finds that service connection for a left shoulder disorder, diagnosed as bicipital tendonitis and arthritis, is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Daniels, 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.