Citation Nr: 21028384 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 17-40 179 DATE: May 11, 2021 ORDER As new and material evidence sufficient to reopen the previously denied claim for service connection for a right wrist disorder has been received, the application to reopen is granted. Entitlement to service connection for a right shoulder disorder, diagnosed as subacromial bursitis, is granted. REMANDED Entitlement to service connection for a right wrist disorder is remanded. Entitlement to service connection for a right elbow disorder is remanded. FINDINGS OF FACT 1. In a May 2012 rating decision, the Regional Office (RO) denied service connection for a right wrist disorder. The Veteran was notified of that decision and of his appellate rights, but he did not appeal or submit new and material evidence within one year. 2. Additional evidence has been received since the final May 2012 rating decision that relates to an unestablished element and raises a reasonable possibility of substantiating the claim for service connection for a right wrist disorder. 3. The Veteran has a current right shoulder disorder, diagnosed as subacromial bursitis, that is related to his military service. CONCLUSIONS OF LAW 1. The May 2012 rating decision that denied service connection for a right wrist disorder is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2011). 2. New and material evidence having been received, the criteria for reopening the claim for service connection for a right wrist disorder have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a) (2020). 3. The criteria for entitlement to service connection for a right shoulder disorder, diagnosed as subacromial bursitis, have been met. 38 U.S.C. § 1131, 5107; 38 C.F.R. § 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1977 to February 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision. The Veteran testified at a hearing before the undersigned Veterans Law Judge in May 2020. A transcript is of record. 1. New and material evidence for the claim of service connection for a right wrist disorder In order to reopen a claim which has been denied by a final decision, a claimant must present new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); see also Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001) (regardless of action taken by Regional Office (RO), the Board must determine whether new and material evidence has been received subsequent to an unappealed RO denial). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For the purpose of reopening, evidence received is generally presumed credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). There is a low threshold for finding new evidence raises a reasonable possibility of substantiating a claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). In a May 2012 rating decision, the RO denied service connection for a right wrist fracture finding that the evidence did not show a current diagnosis or an event, disease, or injury in service. The Veteran was notified of the decision and of his appellate rights; however, he did not file a notice of disagreement or submit new and material evidence within one year of receiving notice of the decision. Therefore, the May 2012 rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2011). The evidence submitted since the May 2012 rating decision includes a November 2015 VA x-ray report that noted an impression of moderate degenerative arthropathy of the first triscaphe joints. A November 2015 VA treatment record also noted that the Veteran had limited range of motion in his right wrist. This evidence relates to a previously unestablished fact and could reasonably substantiate the claim were it to be reopened by triggering VA's duty to assist. See Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Thus, the Board finds that this evidence is both new and material, and the claim for service connection for a right wrist disorder is reopened. 2. Entitlement to service connection for a right shoulder disorder Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The evidence shows that the Veteran has a current diagnosis of a right shoulder disorder. In this regard, a July 2020 medical opinion, a VA physician stated that the Veteran has a current diagnosis of right shoulder subacromial bursitis. Thus, the first element of service connection is satisfied. See Shedden, 381 F.3d at 1166-67. With regard to in-service incident, the Veteran contends that he injured his right shoulder injury during a motorcycle accident while stationed at Beale Air Force Base in 1978. See, e.g., May 2020 Board Hearing Transcript, at 3. The Veteran also reported having ongoing right shoulder pain since his separation from service. See id. at 4. In support of his claim, the Veteran also submitted lay statements from his family and a fellow servicemember. In May 2017 statements, the Veteran's mother and sister stated that he injured his right shoulder in a motorcycle accident while he was stationed at Beale Air Force Base in 1978. In a May 2017 correspondence, S.B. (initials used to protect privacy) stated that he served with the Veteran at Beale Air Force Base. He recounted that the Veteran was involved in a motorcycle accident and injured his shoulder in 1978. In a June 2020 correspondence, the Veteran's sister, M.F., stated that she noticed the Veteran had progressive weakness in his right shoulder since a 1978 accident during service. The Veteran and his family are competent to report observable symptoms and events, including the onset of his symptoms of right shoulder pain. Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds no reason to doubt the credibility of the Veteran's statements regarding the onset and ongoing nature of his right shoulder symptoms. In a July 2020 medical opinion, a VA physician, Dr. M.S., opined that the Veteran's current right shoulder disorder is more likely than not a result of repetitive motions and excessive force while performing his duties during his active military service. In so finding, Dr. M.S. stated that he examined the Veteran and reviewed relevant medical records, including MRI and x-ray findings. He also stated that the Veteran was involved in a motorcycle accident that resulted in an injury to his shoulder. Dr. M.S. stated that the Veteran suffers from a condition called subacromial bursitis, which is an inflammation in the bursa sac. He explained that the bursa is a small sac of fluid that cushions and protects the tendons of the rotator cuff. Dr. M.S. further explained that, during excessive force or repetitive motion, irritation and inflammation of the bursa may occur. On review, the Board finds July 2020 medical opinion is highly probative on this matter, as the opinion was based on a review of pertinent records, examination of the Veteran, and the physician's own medical expertise, training, and knowledge. The opinion is also supported by rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). In addition, the Veteran's DD Form 214 reflects that his military specialty was a fuel specialist, which is consistent with performing duties that require repetitive motion and force. The Veteran's medical records do not contain any negative opinions regarding the etiology of his right shoulder disorder. Based on the positive medical opinion from Dr. M.S. and the Veteran's reports of continuous symptoms, the Board finds the evidence is at least in equipoise that his right shoulder disorder is related to performing his duties during service. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim for service connection for a right shoulder disorder, diagnosed as subacromial bursitis, is granted. REASONS FOR REMAND Initially, the Board notes that the Veteran's service treatment records appear incomplete and do not contain a separation examination. The Veteran also reported that he was hospitalized for injuries sustained from a motorcycle accident at the Beale Air Force Base Hospital in approximately 1978. However, the Board notes that records pertaining to treatment for injuries sustained during a motorcycle accident from that facility are not currently associated with the claims file. Therefore, a remand is necessary for the Agency of Original Jurisdiction (AOJ) to obtain any service treatment, inpatient, or clinical records that may be available. 38 C.F.R. § 3.159(c). 1. Entitlement to service connection for a right wrist disorder The Veteran contends that he has a current right wrist disorder that is related to injuries sustained during an in-service motorcycle accident. See, e.g., March 2016 correspondence. He also reported that his right wrist pain has continued since service. See id. As discussed above, the Veteran's post-service medical records document complaints of limited right wrist range of motion and x-ray findings of moderate degenerative arthropathy of the first triscaphe joints. The Veteran has not been afforded a VA examination and the Board finds that an opinion is warranted to ascertain the nature and etiology of his claimed right wrist disorder. See McClendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (describing the circumstances under which VA's duty to provide a medical examination are triggered). 2. Entitlement to service connection for a right elbow disorder The Veteran contends that he has a current right elbow disorder that is related to injuries sustained during an in-service motorcycle accident. See, e.g., March 2016 correspondence. He also reported having symptoms of pain and difficulty bending his right elbow since service. See May 2020 Board Hearing Transcript, at 9. A November 2015 VA imaging report noted an impression of right elbow olecranon enthesopathy. The Veteran has not been afforded a VA examination and the Board finds that an opinion is warranted to ascertain the nature and etiology of his claimed right elbow disorder. See McClendon, Vet. App. at 83-86. The matters are REMANDED for the following action: 1. Obtain and associate the Veteran's complete service treatment records with the claims file. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. It is noted that the claims file contains copies of service treatment records; however, it appears that these records may be incomplete. 2. Contact the appropriate facilities to request any inpatient or clinical records from the Beale Air Force Base Hospital dated in 1978 that pertain to treatment for right elbow and right wrist injuries sustained during a motorcycle accident. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of any right wrist disorders that may be present. Any and all studies, tests, and evaluations deemed necessary should be performed. (a) The examiner should identify all current right wrist disorders. (b) For each disorder identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's disorder had its onset in service or is otherwise causally or etiologically related to service. In providing this opinion, the examiner should consider the Veteran's lay statement that he has a right wrist disorder that is related to injuries sustained during a motorcycle accident during service. See, e.g., March 2016 correspondence. He or she should also consider the lay statements received in May 2017 and June 2020 from the Veteran's family and friend regarding his reported in-service injury and symptoms since service. A complete rationale for any opinion offered should be provided. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of any right elbow disorders that may be present. Any and all studies, tests, and evaluations deemed necessary should be performed. (a) The examiner should identify all current right elbow disorders. (b) For each disorder identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's disorder had its onset in service or is otherwise causally or etiologically related to service. In providing this opinion, the examiner should consider the Veteran's lay statement that he has a right elbow disorder that is related to injuries sustained during a motorcycle accident during service. See, e.g., March 2016 correspondence. He or she should also consider the lay statements received in May 2017 and June 2020 from the Veteran's family and friend regarding his reported in-service injury and symptoms since service. A complete rationale for any opinion offered should be provided. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Wulff, 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.