Citation Nr: 21023389 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 16-24 356 DATE: April 20, 2021 REMANDED Entitlement to service connection for left shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2003 to March 2005. This case is on appeal before the Board of Veterans’ Appeals (Board) from a September 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In an October 2018 decision, the Board determined that new and material evidence had been received to reopen the claim, and the appeal was remanded for additional development. The appeal was again remanded for further development in July 2020. Entitlement to service connection for left shoulder disability is remanded. Pursuant to the July 2020 remand, the agency of original jurisdiction (AOJ) obtained an addendum opinion concerning the likelihood that the Veteran’s pre-existing left shoulder disability was aggravated by service. In response, an addendum opinion was furnished in October 2020 by a VA contract physician, Dr. T.D. The physician concluded that it was more likely than not that the Veteran’s current shoulder conditions were due strictly to his original pre-service left shoulder injury, not due to events in service, and that there was no evidence of aggravation in service beyond the natural course of the original pre-service injuries. In so doing, the physician found that though the Veteran claimed an injury in service occurring in March 2005 two days prior to separation, and one week after the separation exam, there was no evidence of such an injury. The Board notes that this is factually inaccurate. A March 15, 2005 service treatment record shows that the Veteran was seen for left shoulder pain after feeling a pop in the area while carrying a heavy bag. The diagnostic assessment was left shoulder sprain, an X-ray was negative for fracture and the Veteran was assigned limited duty. Given that the October 2020 physician did not consider this service treatment record indicating that the Veteran’s left shoulder exhibited some symptomatology during service and incorrectly found that there was no evidence of such an injury, the Board is not able to rely on the October 2020 opinion to determine the likelihood that the Veteran’s pre-existing shoulder disability was aggravated by service. Consequently, an addendum, which includes review of the March 2005 service treatment record, is necessary prior to final adjudication of this claim. Thus, the appeal must be remanded to obtain this addendum. In providing the addendum, the examiner should also consider any pertinent evidence added to the record since the original opinion, including the record of an October 2020 visit with a VA orthopedic surgeon. Prior to arranging for the addendum opinion, the AOJ should obtain updated VA treatment records dated from November 2020. The matter is REMANDED for the following action: 1. Obtain VA treatment records dated from November 2020. 2. Obtain an addendum opinion to the October 2020 medical opinion. The examiner should review the pertinent information in the claims file, including the October 2020 opinion. The examiner should also specifically review the service treatment record dated March 15, 2005, which shows that after lifting a heavy bag, the Veteran suffered some level of left shoulder injury, which was diagnosed as a left shoulder sprain, for which an X-ray was negative for fracture, and for which the Veteran was assigned limited duty. Additionally, the examiner should review any pertinent evidence added to the record after he rendered his October 2020 opinion, including an October 2020 VA orthopedic surgery note, which notes August 2020 MRI findings (irregularity of the anterior labrum of uncertain significance, possible reverse Hill-Sachs lesion but not entirely clear, significant internal rotation of the humeral head relative to the glenoid and rotator cuff intact with no significant atrophy). The examiner should then provide an addendum opinion, which addresses following questions: A) Did the Veteran’s pre-existing left shoulder disability increase in severity during service, including due to the shoulder sprain documented by the March 15, 2005 service treatment record? (Continued on the next page)   B) If the Veteran’s left shoulder disability did increase in severity during service, was it due to the natural progress of the left shoulder condition? The examiner should explain the rationale for the opinion(s) provided. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dan Brook, 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.