Citation Nr: 21023714 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 16-15 080A DATE: April 21, 2021 REMANDED Entitlement to service connection for a right shoulder disorder, to include as secondary to service connected posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active service from July 2012 to July 2013. He had additional service in the Army National Guard. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in September 2018 and September 2020, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. Although the Board regrets the additional delay, another remand is necessary to ensure that there is a complete record on which to decide the Veteran’s claim. 1. Right Shoulder Disorder The Veteran asserts that his right shoulder disorder is related to his active service. Specifically, the Veteran asserts that his claimed disorder was due to combat body armor and carrying supplies during his active service. In the alternative, the Veteran asserts that his right shoulder disorder is related to his service-connected posttraumatic stress disorder (PTSD). See claim, received by VA July 14, 2016. The Veteran’s representative asserted that the Veteran saw a chiropractor in 2013 regarding his right shoulder disorder and that this evidence was not considered by the October 2020 examiner. See Representative Statement, March 23, 2021. After a review of the clinical records in evidence, the Board was unable to find any record from a private chiropractor. As such, they must be obtained on remand as they are pertinent to the issue on appeal. In September 2020, the Board remanded the instant claim for an etiology opinion as to direct service connection. The Board instructed the VA examiner to discuss the Veteran's statements regarding his in-service symptomology, to include the July 2020 statement regarding an eight-foot fall from a truck in October or November of 2012 as well as an October 2013 X-ray that was interpreted to reveal slight widening of the right acromioclavicular joint that could reflect a history of prior type II acromioclavicular joint separation. The Veteran underwent an examination in October 2020. See Medical Opinion Disability Benefits Questionnaire (DBQ), October 1, 2020. The examiner opined that the Veteran’s right shoulder disorder was less likely as not related to his service, as his service treatment records were silent for any injury on active duty. The examiner did not address the impact, if any, of the October 2013 X-ray. In addition, the examiner did not consider whether the Veteran’s right shoulder disorder was secondary to his service connected PTSD. On remand, an addendum opinion should be obtained. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained. Specifically, obtain the outstanding medical records from the Veteran’s private chiropractor pertaining to right shoulder issues, to include those from 2013. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. 2. Return the claims file to the examiner who conducted the October 2020 right shoulder examination for an addendum opinion, if available. A complete and detailed rationale should be given for all opinions and conclusions expressed. The need for further in-person examination is left to the discretion of the examiner. The examiner should once again review the claims file and provide an addendum opinion clarifying the following: (A) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s right shoulder disorder is related to, or had its onset in, his active service? The examiner should discuss the Veteran’s assertions that he experienced continuity of symptomatology related to his right shoulder since active service. The examiner should discuss the impact, if any, of an October 2013 X-ray that was interpreted to reveal slight widening of the right acromioclavicular joint that could reflect a history of prior type II acromioclavicular joint separation. (B) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s right shoulder disorder was caused or aggravated by his service-connected PTSD? A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Lech, 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.