Citation Nr: 21028514 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 18-19 214 DATE: May 11, 2021 REMANDED Entitlement to a right shoulder condition is remanded. REASONS FOR REMAND The Veteran served on active duty from February 27, 1996 to March 26, 1996. In March 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In June 2020, the Board reopened the Veteran's clam for entitlement to service connection for hallux rigidus of the right foot. The Board remanded that appeal and the Veteran's claim for entitlement to a right shoulder disability for further development. Based on the development while the appeal was pending, in a September 2020 rating decision, the RO granted the Veteran's claim for service connection for hallux rigidus of right foot. Given that decision represents a full grant of benefits sought, the issue of entitlement to service connection for hallux rigidus is no longer on appeal. Unfortunately, with respect to the Veteran's claim for entitlement to service connection for a right shoulder condition, the Board finds another remand is warranted. In June 2020, the Board remanded this claim pursuant to the Veteran's Board hearing testimony indicating he had a right shoulder replacement. The Board notes that the record at that time did not contain evidence of a right shoulder replacement. Upon remanding the claim, the Veteran submitted medical records from Barbour Orthopaedics, in which, Dr. S.B. opined that the Veteran had severe osteoarthritis of the right shoulder. Dr. S.B. noted that in November 2019, the Veteran underwent a right shoulder hemiarthroplasty. Although the examiner opined that it is more likely than not that the Veteran's right shoulder condition was caused by an injury in service, the examiner explicitly stated that "no prior medical records were provided." Given that the examiner did not review the Veteran's medical history, the Board finds that this opinion lacks probative value and an addendum medical opinion is warranted. The matters are REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain any outstanding records relevant to the Veteran's right shoulder claim, to include records provided by Barbour Orthopaedics. All attempts to obtain these records must be documented in the claims file. The RO should follow the procedures for obtaining the records set forth by 38 C.F.R. § 3.159 (c). If VA attempts to obtain any outstanding records which are unavailable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159 (e). 2. Upon completion of the above to the extent possible, obtain an addendum medical opinion from a qualified medical professional, an orthopedic specialist if available, to ascertain the nature and etiology of the Veteran's right shoulder condition. After reviewing the entire record, (to include the STRS), the examiner should provide an opinion responding to the following: Whether the Veteran's right shoulder condition, to include severe osteoarthritis and right shoulder hemiarthroplasty, is at least as likely as not (probability of 50 percent or greater) the result of a disease or injury incurred in or aggravated by service. The examiner should discuss the Veteran's lay statements regarding the history and chronicity of symptomatology. S/he should outline that history in the report. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, a reason for doing so must be provided. Any opinion expressed by the VA examiner must "contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Abdelbary, 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.