Citation Nr: 21025487 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 17-28 186 DATE: April 28, 2021 REMANDED Entitlement to service connection for bilateral shoulder conditions is remanded. REASONS FOR REMAND The Veteran served in the United States Navy on active duty from February 1995 to December 2003. The issue comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in April 2020. A transcript of the hearing has been included with the record. The Board previously remanded the above issue in July 2020 to provide a VA examination and medical opinion. Although the Board regrets further delay, another remand is necessary to provide the Veteran with every possible consideration. Further development is necessary to provide the Veteran with an adequate VA medical opinion addressing the Veteran’s lay evidence of continued bilateral shoulder pain since service. Entitlement to service connection for bilateral shoulder conditions is remanded The Veteran’s service treatment records showed the Veteran suffered a left shoulder muscle strain in October 1995. The Veteran’s service treatment record states the Veteran noticed the pain when she was doing pushups. Additionally, in a January 2003 service treatment record, the Veteran complained of pain of the right upper back after moving a dresser the day before. The treating physician diagnosed the Veteran’s injury as a muscle strain. The Veteran’s VA medical treatment records from October 2016 demonstrate the Veteran complained of bilateral shoulder pain. The Veteran received occupational therapy to address the pain. The VA orthopedist noted the Veteran’s MRI showed a rotator cuff tear of the right shoulder. The VA orthopedist also provided the diagnosis of tendinopathy of the left shoulder. The Veteran underwent a VA examination in August 2014. The VA examiner did not perform an examination on the Veteran’s left shoulder. Pursuant to the Board remand, the Veteran underwent a VA examination in December 2020. The VA examiner confirmed the diagnosis of shoulder strain of both left and right shoulders and provided the diagnosis of degenerative arthritis of both the Veteran’s shoulder joints. The VA examiner noted the Veteran reported the onset of her shoulder pain was in 1998. The examination noted the Veteran asserted that her condition has worsened since onset. The VA examiner provided the medical opinion that the Veteran’s bilateral shoulder condition was less likely than not incurred in or caused by the claimed in-service injury or event. The VA examiner rationalized that the Veteran did not possess a chronic diagnosis for bilateral shoulder pain. The VA examiner noted the record did not contain sufficient documentation to confirm chronicity of care for the Veteran’s bilateral shoulder condition. Here, the Board finds an addendum opinion is required to address the Veteran’s lay testimony, to include that she experienced shoulder pain since the onset of her bilateral shoulder condition in service. The December 2020 VA examination provided that there was insufficient documentation regarding chronicity of care. However, the VA examiner’s opinion did not consider the Veteran’s competent lay statements addressing the history of her bilateral shoulder pain. The Board acknowledges that as a lay person the Veteran is competent to provide opinions on certain subjective medical issues and of observable symptomatology, to include pain. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Accordingly, an addendum opinion is required to address the Veteran’s lay evidence of shoulder pain since service and how it may relate to the Veteran’s current disabilities. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the examiner who provided the December 2020 VA opinion, or, if not available, another appropriately qualified VA medical professional. If the examiner determines that an examination is needed to provide the requested opinion, then such examination should be scheduled and may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic. The claims file should be reviewed in conjunction with the examination. A copy of this remand should be made available to the examiner. Following a review of the entire record, the Veteran’s competent lay statements, as well as the Veteran’s testimony regarding the onset and progression of her shoulder pain, the examiner should opine as to the following: Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s bilateral shoulder conditions, to include shoulder strain and degenerative arthritis, were incurred in or were caused by the claimed in-service injury, event or illness. The examiner must provide a comprehensive report including a clearly stated rationale for any opinions offered and conclusions reached, citing the objective medical findings leading to the conclusions, and must not be based solely on the lack of records. In this regard, the Board emphasizes that the Veteran is competent to report her symptoms and history of shoulder pain, and such statements by the Veteran regarding symptomatology and medical history must be specifically acknowledged and considered in formulating any opinions concerning the onset and severity of her disability. If such reports are rejected by the examiner, a reason for doing so must be provided. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.V. Bona, 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.