Citation Nr: 21025218 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 16-01 083 DATE: April 27, 2021 REMANDED Entitlement to service connection for a right shoulder disorder (claimed as right chest condition) is remanded. Entitlement to service connection for left shoulder impingement syndrome and rotator cuff tear is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from April 1971 to July 1975 and from October 1975 to April 1978. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The matter last appeared before the Board in September 2018, at which time the issues were remanded for further development. The Board finds that remand is again warranted for the reasons noted below. Entitlement to service connection for a right shoulder disorder (claimed as right chest condition) is remanded. The Veteran underwent a shoulder and arms examination in July 2019. The examiner opined that the Veteran’s right chest condition is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner rationalized that upon review of all available medical evidence, the Veteran claims a right chest condition, but on examination, the Veteran is referring to radiating right shoulder pain due to impingement. The examiner found that there is no distinct right upper chest pain and a nexus has not been established. The examiner concluded that therefore, it is less likely than not that the claimed condition warrants direct service connection. In a June 2020 statement, in regard to his right chest condition, the Veteran stated that he advised the examiner that the area where the pain and restrictive movement was located, which was in his upper chest or lower shoulder, but the examiner ignored his complaint. Here, the Board notes that although the examiner opined that the Veteran does not have a diagnosed right chest condition, she found that the Veteran was referring to radiating right shoulder pain due to impingement, and further diagnosed the Veteran with right shoulder impingement syndrome. However, the examiner did not opine as to whether the diagnosed disability is related to a 1973 in-service motorcycle accident. The Board notes that while the Veteran is not competent to opine on the etiology of a condition, he is competent to report his symptoms relating to his claimed condition, and these reports should be considered by any future examiner. Clyburn v. West, 12 Vet. App. 296, 301 (1999). The Board must also consider any disability that “may reasonably be encompassed by” the description of the claim and symptoms or other submitted information. Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009). As such, the Board has recharacterized the claim to encompass a disability reasonably encompassed by the description. As such, as the examiner diagnosed the Veteran with a right shoulder condition but did not provide an opinion as to whether the disability is related to service, remand is warranted to obtain such opinion. Entitlement to service connection for left shoulder impingement syndrome and rotator cuff tear is remanded. The July 2019 examiner opined that the Veteran’s left shoulder condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner rationalized that upon review of all available medical evidence, even though Veteran is a credible historian and contends the 1973 motor bike accident resulted in a left shoulder condition, there is no documentation in file. The examiner remarked that the accident resulted in a left wrist fracture, not left shoulder problems. The examiner found that it is more reasonable to conclude that he compensated for his disabled right shoulder, by overuse of his left shoulder and therefore, a nexus has not been established. The examiner concluded that it is less likely than not that the claimed condition has direct service connection. In the June 2020 statement, the Veteran stated that when the 1973 accident happened, he was riding a motorcycle with both hands on the handle bar when he hit the ditch, and the left mirror broke his left arm as he was violently thrown from his bike, twenty to thirty feet into the woods resulting in several cuts and abrasions, indicating that it is possible that his shoulders were pulled and twisted during the accident, despite the lack of a concrete shoulder diagnosis at that time. Here, although the examiner rationalized that the Veteran was overcompensating for his right shoulder disability by using his left shoulder, the examiner did not adequately explain if the overuse of the left shoulder is nonetheless, ultimately due to the December 1973 accident, and he did not fully consider the Veteran’s assertions regarding the severity of his injuries from the 1973 accident and his on-going shoulder pain. The opinion is therefore inadequate, and a new opinion is requested. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any updated VA medical records and private treatment records not previously obtained. 2. Request an addendum medical opinion to address the etiology of the Veteran’s right shoulder and left shoulder disabilities. The examiner should note that the claims folder was reviewed. If the examiner determines that an opinion cannot be rendered without examination of the Veteran, then an examination should be provided. An in-person examination may be scheduled if the examiner deems it necessary, or it may be conducted via telehealth during social distancing restrictions. After reviewing the claims file and examining the Veteran, if deemed necessary, the examiner should opine to the following for each claim, the right shoulder and left shoulder disabilities: a) What are the Veteran’s current diagnoses relating to his upper chest, right shoulder, and left shoulder? b) For all disorders found, is it at least as likely as not (probability of fifty percent or greater) that the condition had its onset during the Veteran’s active service, or is related to any in-service disease, event, or injury, to include the December 1973 motorcycle accident? The examiner is asked to directly address the Veteran’s June 2020 statements indicating that his shoulders were violently pulled and twisted from the accident after being violently thrown from his bike, twenty to thirty feet into the woods resulting in several cuts and abrasions. If the Veteran’s lay statements are not found to be credible, the examiner must explain why. (Continued on the next page)   A complete and fully explanatory rationale must be provided for any opinion offered.  If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. Mary E. Rude Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Q. Alli, Associate 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.