Citation Nr: 21025611 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 17-12 267 DATE: April 28, 2021 REMANDED Entitlement to service connection for shoulder impingement syndrome claimed as right shoulder injury is remanded. Entitlement to service connection for disc degeneration claimed as a lumbar injury is remanded. REASONS FOR REMAND The Veteran had active service from April 1986 to June 1993. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Saint Paul, Minneapolis. The Veteran testified at a Board virtual hearing before the undersigned in March 2021. A transcript of that hearing is associated with the claims file. 1. Entitlement to service connection for shoulder impingement syndrome claimed as right shoulder injury. The Veteran asserts that his current shoulder disability is directly related to service. The Veteran says he has not recovered from the initial injury to his shoulder. He reports that he has very limited movement of the shoulder and was not afforded proper medical care for his injuries while on active duty and out to sea. See Form 9 Received March 2017. The Veteran asserts that he hurt his shoulder in the military when he was cleaning the bilge of the ship and was hit with a large nut on his shoulder. The Veteran also asserts that since that incident he cannot lift his arm above his shoulder without pain. See Notice of Disagreement Received May 2016. During the Veteran’s March 2021 hearing, the Veteran testified about the origin of his shoulder disability. The Veteran testified that he injured his shoulder sometime between 1986 and 1987. He stated that when they were coming into the port from being out to sea for three months and were told to get the spaces clean. He was reaching down in the bilge to pick up a piece of paper and as he reached down there was a coupling on the shaft of the ship that spins around and as it was spinning it caught his right shoulder and threw him up against the bulkhead and lacerated his shoulder. The Veteran testified that his shoulder started swelling and he could not move. He stated that he was taken to the hospital and they took x-rays and indicated that there was nothing broken. The Veteran states that he had to keep it in a sling for about a week and was told to return if it started bothering him. Additionally, the Veteran testified that he was treated for his shoulder at the Naval hospital at Mayport Florida and asserts this is documented in the records. Furthermore, the Veteran testified that he experienced ongoing pain and sought treatment for his shoulder at the VA and he would sometimes self-medicate with Advil or Tylenol. The Veteran states that there has always been constant pain in his shoulder since the incident. The Veteran says he didn’t report complaints related to his back and shoulder at his separation examination because he was excited getting out of the service to go to work for the railroad. See Hearing Transcript dated March 2021. The Veteran’s entrance examination and separation examinations are silent for any complaints, symptoms or injuries related to his shoulder. The Veteran’s service treatment records (STRs) include several notations related to the shoulder injury that the Veteran sustained in service. In an undated treatment note that contains a stamp that says Douglas R. Johnson, it is noted that the Veteran complained that his right arm was hit by a shaft on his boat and that he experiences pain when he tries to lift his arm above shoulder level. An August 1987 STR states that the Veteran complains of trauma to his right shoulder as a result of being struck by a shaft. Additionally, it is noted that the Veteran suffered an abrasion to the right shoulder and swelling. It is further noted that the Veteran has a contusion of the right shoulder and was prescribed motrin and had to wear a sling. The Veteran’s post service treatment records include several complaints related to issues with shoulder pain. The Veteran was afforded a VA examination June 2015 for his right shoulder condition. The examiner diagnosed the Veteran’s right shoulder impingement syndrome but opined that it was less likely than not related to service. The examiner noted that the Veteran was seen in service for his right shoulder for a contusion due to being hit by a small bolt and a shoulder strain from lifting weights in 1998; however, his STRs show no indication of a mechanical cause for his current impingement. The Board finds that remand is necessary to obtain an addendum opinion. While the June 2015 examiner considered, the in-service incident in which the Veteran was hit by a shaft, the Veteran has since provided additional details about the date and circumstances of that incident. Moreover, the Board notes the examiner’s report did not provide any details in the history section as to how or when the Veteran asserts his right shoulder onset. The Veteran has since clarified that his shoulder pain began in and has been continuous since service. Therefore, the Board finds that remand is warranted. 2. Entitlement to service connection for disc degeneration claimed as a lumbar injury. The Veteran asserts that his current back disability is directly related to service. The Veteran states that the VA is too focused on the diagnosis of age related degeneration of his back and not the injury he suffered in service. Additionally, the Veteran says the in-service injuries to his back are the root of his back problems. See Form 9 Received March 2017. The Veteran asserts that as a diesel mechanic he lifted heavy objects all the time and his lower back has consistently caused him pain. See Notice of Disagreement Received May 2016. During the Veteran’s March 2021 hearing he testified about the origin of his back disability. The Veteran testified that he injured his back when lifting up hatches at the general quarters. The Veteran testified that he sought treatment at the time of the injury occurred and the doctor on the ship told him that it was a lower lumbar strain. The Veteran also testified that he was given time off and believes that he re-injured his back again at different times. The Veteran stated that he has had different doctors since service and self-medicated the pain in his back with Tylenol or Advil and a heading pad or by sitting in a chair. The Veteran further testified that his back issues have been ongoing since separating from service. The Veteran also states that the record reflects that he underwent physical therapy when he was stationed in “Orange” and he further states that he went to physical therapy in Port Arthur for two to three months. During the hearing, the Veteran confirmed that he has the same symptoms he experienced after service today including back pain in the same spot where he initially injured his back. The Veteran also testified that he injured his back again when lifting weights while on the ship during active duty service when they were at sea. The Veteran stated that he has not had any injuries to his back after service. Moreover, the Veteran testified that doctors have told him that his back and shoulder conditions are related to age; however, the Veteran stated that he is experiencing the same symptoms for both his back and shoulder that he experienced during service and since leaving service and believes that they are related to service. See Hearing Transcript dated March 2021. The Veteran’s entrance examination and separation examinations are silent for any complaints, symptoms or injuries related to his back. The Veteran’s service treatment records (STRs) include several notations related to the back injuries that the Veteran sustained in service. A record from February 1989 noted that on this day the Veteran complained of trauma to the head and neck pain. It is further noted that the Veteran injured his head when he ran a ladder into a closed hatch. The note also stated that the Veteran experienced tenderness in the C-spine, discoloration, discomfort, and spine deformity. It was documented that the Veteran had a neck and back strain. An April 1988 STR states that the Veteran complained of lower back pain. It was further noted that the Veteran was lifting weights when he injured his back. Tenderness was noted as present in the lower lumbar spine and the Veteran was prescribed Motion 600. An October 1990 service treatment note from the ambulatory care center indicates that the Veteran was in a car accident and hurt his back; the record notes a contusion of the back and the Veteran was unfit for duty for 2 days. The Veteran’s post-service treatment records include several complaints documenting issues related to lower back pain. The Veteran was afforded a VA examination in June 2015 and diagnosed with degenerative arthritis of the spine. The VA examiner opined that the Veteran’s back disability is less likely than not incurred in or caused by service. The examiner noted two episodes of back strain in 1991 and 1998, but that the Veteran’s examinations were normal. The examiner opined that the Veteran’s current complaints are of disc degeneration with back pain that is due to his age. The Board finds that remand is necessary to obtain an addendum opinion. The examiner did not specify which examinations were normal. In addition, the June 2015 examiner did not consider the Veteran’s statements this his back pain began in service and has continued since service. Finally, while the examiner noted the Veteran’s 1998 back injury, the examiner did not consider the STRs documenting a neck injury in February 1989 and a car accident that resulted in limitation of duties due to back injuries sustained in October 1990. As such, remand for an addendum medical opinion is warranted. The matters are REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding records pertaining to treatment or evaluation of the Veteran’s disabilities at issue, to include both VA and private records. 2. Provide the Veteran with an appropriate examination to determine the etiology of his claimed right shoulder disability. This entire remand decision and the entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner is asked for the following: (a.) Please all right shoulder related disabilities by either (1) diagnosis or (2) functional impairment. (b.) For each identified right shoulder disability, opine whether it is at least as likely as not (i.e., a 50 percent probability or greater) had its clinical onset during or is otherwise related to the Veteran’s military service. If any such diagnosed disability cannot be regarded as having had its onset during active service, the examiner should explicitly indicate so. The examiner is asked to explicitly indicate whether it is at least as likely as not that the ongoing shoulder pain that the Veteran currently experiences is the same as that which he experienced in service. In providing an opinion, the examiner must address the following: (1) the Veteran’s statements and testimony regarding his injuries in service and his assertions of ongoing problems since service. Specifically address the assertions regarding an incident during active duty when a coupling on the shaft of the ship that spins around caught the Veteran’s right shoulder and threw him up against the bulkhead and lacerated his shoulder preventing him from being able to move his shoulder and causing ongoing shoulder pain. (2) The STRs noting a right shoulder injury to include: (a) an undated treatment note that contains a stamp that says Douglas R. Johnson, that states that the Veteran complained that his right arm was hit by a shaft on his boat and further notes that he experiences pain when he tries to lift his arm above shoulder level, (b) an August 1987 STR that states that the Veteran complains of trauma to his right shoulder as a result of being struck by a shaft and further states that the Veteran experienced swelling and sustained an abrasion to the right shoulder and had to wear a sling. The Veteran is competent to say he experienced shoulder pain during service and ongoing shoulder pain following service even if there is no documentation of such complaints in his post-service treatment records immediately following active duty service. The examiner should acknowledge and consider the fact that the reason the Veteran did not report complaints related to his shoulder during his separation examination was because he did not want it to interfere with a pending employment opportunity. The examiner should also set forth medical reasons for accepting or rejecting the Veteran’s reports (lay observations). 3. Provide the Veteran with an appropriate examination to determine the etiology of his claimed back disability. This entire remand decision and the entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. The examiner is asked for the following: (a.) Please identify all back related disabilities by either (1) diagnosis or (2) functional impairment. (b.) For each identified back disability, opine whether it is at least as likely as not (i.e., a 50 percent probability or greater) had its onset during or is otherwise related to service the Veteran’s military service. If any such diagnosed disability cannot be regarded as having had its onset during active service, the examiner should explicitly indicate so. The examiner is asked to explicitly indicate whether it is at least as likely as not that the ongoing back pain and back disabilities that the Veteran currently experiences is the same or a manifestation of that which he experienced in service. In providing an opinion, the examiner must address the following: (1) the Veteran’s statements and testimony regarding his multiple back injuries in service and his assertions of ongoing problems since service. Specifically, the examiner must address (a) Specifically, address the testimony that he was diagnosed with a lower lumbar strain after he injured his back when lifting up hatches at the general quarters during active duty. (b) Also, specifically address the testimony that the Veteran injured his back again when lifting weights while on the ship during active duty service when they were at sea. (c) Address the Veteran’s testimony that he experiences back pain in the same spot where he initially injured his back in service. (Continued on the next page)   (2) STRs noting a back injury to include the following: (a) an incident dated February 1989 that notes that on this day the Veteran complained of trauma to the head and neck pain and experienced tenderness in the C-spine, discomfort, and spine deformity after he ran a ladder into a closed hatch (b) an April 1988 STR that states that the Veteran experienced tenderness and complained of lower back pain relating to lifting weights (c) an October 1990 STR note from the ambulatory care center that indicates that while in service, the Veteran was in a car accident and hurt his back. The Veteran is competent to say he experienced back pain/back strain during service and ongoing back pain following service even if there is no documentation of such complaints in his post-service treatment records immediately following active duty service. The examiner should acknowledge and consider the fact that the reason the Veteran did not report complaints related to his back during his separation examination was because he did not want it to interfere with a pending employment opportunity. The examiner should also set forth medical reasons for accepting or rejecting the Veteran’s reports (lay observations). Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dorsey-Kwansa, 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.