Citation Nr: 21025035 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 15-25 641 DATE: April 27, 2021 ORDER Service connection for the Veteran’s right shoulder disability, as currently diagnosed, is granted. REMANDED Entitlement to service connection for hypertension is remanded. FINDING OF FACT The Veteran’s diagnosed right shoulder disability is at least as likely as not related to service. CONCLUSION OF LAW The criteria for service connection for the Veteran’s right shoulder disability, as currently diagnosed, 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 from January 1966 to December 1969. These matters come before the Board of Veterans’ Appeals (Board) from a September 2014 rating decision. The Veteran testified at a Board hearing in August 2016. The Board remanded these matters in December 2016, June 2019, December 2019, June 2020, and January 2021. Service connection for the Veteran’s right shoulder disability, as currently diagnosed, is granted. The Veteran seeks service connection for a shoulder disability, claimed as arthritis. 07/09/2013, Statement in Support of Claim. Private treatment records show that the Veteran underwent surgery for his right shoulder in November 2013; the relevant treatment note shows diagnoses of massive rotator cuff tear, biceps tendon tear, and acromioclavicular joint osteoarthritis. 04/25/2014, Medical Treatment Record -Non-Government Facility, at 4-6; see also 08/02/2017, C&P Exam. The Veteran asserts that his current shoulder disability is related to strenuous work (e.g., working in tight spaces and in uncomfortable positions, lifting heavy objects) as a missile system mechanic in the Navy. At his August 2016 Board hearing, he reported that he experienced shoulder pain in service but acknowledged that he never sought treatment for it. 08/22/2016, Hearing Transcript, at 4-5. The Board also notes that the Veteran’s December 1969 separation examination is negative for any shoulder abnormalities. Regarding treatment post-service, the Veteran recently stated that he first sought treatment for his right shoulder in 1977 or 1978. 07/09/2019, C&P Exam. (He separated from service in December 1969.) In December 2019, the Board remanded for a new VA examination regarding the etiology of the Veteran’s shoulder disability. In February 2020, a VA examiner opined that Veteran’s shoulder disability was less likely than not related to service. The examiner acknowledged the Veteran’s reports of shoulder pain in service as well as his assertion that his shoulder disability is related to strenuous work in service. In this regard, the examiner determined that “it is likely and should be considered that the Veteran potentially had shoulder pain and performed strenuous work during service.” Nevertheless, the examiner concluded that “there are insufficient records to establish any service connection.” More specifically, the examiner noted that there were no records of shoulder complaints or a shoulder injury in service. The examiner further noted that the Veteran first sought treatment for his shoulder approximately 44 years after service. As discussed in the June 2020 Board remand, this opinion is inadequate because it failed to discuss the extent to which the Veteran’s current disability is a progression of his in-service symptoms and relies on the absence of documented treatment to rule out a nexus. In October 2020, VA obtained a new opinion regarding the etiology of the Veteran’s shoulder disability. The VA examiner opined that the Veteran’s shoulder disability was less likely than not incurred in service or caused by an injury in service. In her rationale, the examiner noted that medical records were silent for a diagnosis, treatment, complaints of a shoulder condition. The examiner explained that there was “no disruption to the articular surface of the joint on AD” and therefore, the Veteran’s arthritis is mostly due to the natural aging process. The examiner further noted that the Veteran worked as a carpenter after service (starting in 1970), then transitioned to work as a telecommunications manager. Regarding the Veteran’s statements that he was assessed for his shoulder in 1977 or 1978, the examiner noted that these statements were not supported by the evidence. The examiner also suggested that the Veteran’s complaints from 1977 or 1978 could be due to his work as a carpenter, which the examiner described as strenuous. Based on these factors, the examiner concluded that the Veteran’s shoulder disability was not related to service and that his arthritis did not manifest within one year after separation from service. As discussed in the January 2021 Board remand, this VA opinion is also inadequate, because it did not address the Veteran’s contention that his shoulder disability is related to strenuous work (e.g., working in tight spaces and in uncomfortable positions, lifting heavy objects) as a missile system mechanic in the Navy. In January 2021, VA obtained a new VA opinion. As to whether the Veteran’s shoulder disability was incurred in, or directly related to, service, the VA examiner acknowledged the Veteran history of shoulder pain and strenuous work in service, but concluded that the current shoulder disability “could very well” be related to the Veteran’s post-service work as a carpenter. The rationale for this conclusion was that service treatment records were silent for a shoulder condition and that carpentry work can result in conditions like those incurred by the Veteran. The examiner further opined that the degenerative joint disease of the right shoulder is more likely than not due to the normal aging process, adding that there was no evidence in the service treatment records of a chronic left shoulder condition. Once again, a VA opinion relies on the absence of corroborating evidence to rule out a nexus. Specifically, the opinion of the January 2021 VA examiner is based on the absence of service treatment records showing a chronic shoulder condition. As such, the January 2021 VA opinion has limited probative value. Notwithstanding the shortcomings of the January 2021 VA opinion, the Board finds that there is sufficient evidence of record to adjudicate the Veteran’s claim. More specifically, the Board finds that the evidence supports a finding that the Veteran’s diagnosed right shoulder disability is at least as likely as not related to service. As noted above, at least two VA examiners have opined that the Veteran’s right shoulder disability is related to his post-service work as a carpenter. As the Board interprets these opinions, the examiner implicitly recognized the possibility that the Veteran’s right shoulder disability could also and to some extent be related to the strenuous nature of his in-service work. To the extent that the Veteran’s right shoulder disability could be related to both his in-service work and his post-service work, the Board finds that there is doubt as to which of the two contributed to the Veteran’s right shoulder disability. In other words, the Board finds that the preponderance of the evidence fails to establish that one cause had more weight than the other. Therefore, the evidence is in relative equipoise. Resolving doubt in favor of the Veteran, the Board finds that his diagnosed right shoulder disability is at least as likely as not related to the shoulder pain experienced in service. Finally, the Board notes that there is no evidence of a diagnosed left shoulder disability. While an August 2017 VA examination references left shoulder pain, that same examination indicates that this pain was secondary to an accident several weeks earlier. In the absence of evidence that the Veteran has a left shoulder disability that could be related to service, the grant of service connection is limited to diagnosed right shoulder disability. REASONS FOR REMAND Entitlement to service connection for hypertension is remanded. The Veteran seeks service connection for hypertension. Private treatment records submitted by the Veteran show a diagnosis of hypertension since February 2014. 04/25/2014, Medical Treatment Record -Non-Government Facility, at 3. Nonetheless, in his May 2013 claim, the Veteran indicated that his hypertension began in 1970. 05/08/2013, VA 21-526 Veterans Application for Compensation. The Veteran separated from service in December 1969. His December 1969 separation examination shows a blood pressure reading of 138/86 but is negative for any significant medical history. 09/27/2011, STR –Medical, at 5. Recent medical records show a history of, and treatment for, hypertension. There is, however, no clear indication of when hypertension was first diagnosed or when treatment for hypertension started. Other than the Veteran’s indication that his hypertension started in 1970, he has not submitted any lay or medical evidence to establish that his hypertension was diagnosed in service or within one year after separation of evidence. Regarding the Veteran’s assertion that his hypertension started in 1970, while he is competent to report any observable symptoms and history of treatment, he is not competent to diagnose hypertension or provide a medical opinion as to the etiology of his current diagnosis of hypertension. The Veteran underwent a VA examination in February 2020. The examiner opined that it was less likely than not that the Veteran’s hypertension began in service or manifested within one year of separation from service. Regarding secondary service connection, the examiner simply indicated that “[t[here is no evidence in current medical literature to establish anxiety or other mental condition as causative for hypertension. Anxiety may only cause temporary spikes in blood pressure but does not cause hypertensive disease.” As discussed in the June 2020 Board remand, this opinion is inadequate because it does not adequately address the aggravation prong of secondary service connection. In October 2020, VA obtained a new opinion regarding the etiology of the Veteran’s hypertension. The VA examiner opined that the Veteran’s hypertension was less likely than not incurred in service or within one year after service or caused or aggravated by his service-connected mental health disability. In her rationale, the examiner explained that the Veteran’s blood pressure reading at separation did not support a diagnosis of hypertension. The examiner further noted that there was no medical record of a diagnosis of hypertension within one year after separation from service, adding that, according to VA treatment records, the Veteran’s hypertension was diagnosed around 2009, decades after service. Regarding secondary service connection, the examiner explained that Veteran’s hypertension was not related to his service-connected mental health disability, as both disabilities are separate and unrelated entities, with no causal relationship shown in the medical literature. As for the aggravation prong of secondary service connection, the examiner’s rationale consisted of a detailed explanation of the pathophysiology of hypertension. As discussed in the January 2021 Board remand, this VA opinion is inadequate because it lacks a clear rationale, despite the examiner’s thorough discussion of the pathophysiology of hypertension. In January 2021, VA obtained an addendum opinion, focusing on secondary service connection. The VA examiner opined that the Veteran’s hypertension was not caused or aggravated by his service-connected disability. The examiner’s rationale was simply that “there is no evidence in the provided service treatment records indicating that the veteran was diagnosed with hypertension while on active duty or within one year of his discharge from active duty.” This rationale is patently inadequate as it does really address the question of secondary service connection. As such, it did not comply with the Board’s remand directive. Stegall v. West, 11 Vet. App. 268, 271 (1998). Another remand is therefore necessary. The Board regrets the additional delay, but it is necessary to ensure the Veteran’s right to a decision that is based on an adequate record.   This matter is REMANDED for the following action: Obtain an addendum opinion regarding the etiology of the Veteran’s hypertension. The examiner must opine whether the Veteran’s hypertension is at least as likely as not (1) proximately due to his service-connected mental health disability, OR (2) aggravated beyond its natural progression by his service-connected mental health disability. **In doing so, the examiner is asked to please lay out the journey to their conclusion, to include consideration of the relevant factors in this Veteran’s medical history.** If an opinion cannot be given without resorting to speculation, the examiner should explain why and 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), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. López, 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.