Citation Nr: 21032106 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 15-41 515 DATE: May 25, 2021 REMANDED Whether new and material evidence has been presented to reopen a claim for service connection for a low back disability, to include as secondary to service-connected residuals of right total shoulder arthroplasty, is remanded. Entitlement to service connection for a neck disability, to include as secondary to service-connected residuals of right total shoulder arthroplasty, is remanded. Entitlement to service connection for headaches, to include as secondary to service-connected residuals of right total shoulder arthroplasty, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1971 to August 1973 with additional unverified reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision. In November 2018, the Veteran and a witness testified before the undersigned Veterans Law Judge (VLJ) at a video-conference hearing. A transcript of that hearing is of record. The Veteran's claims were remanded by the Board in October 2020. Subsequent to the remand, a March 2021 rating decision granted service connection for posttraumatic stress disorder (PTSD) with major depressive disorder and unspecified anxiety disorder. As this represents a full grant of the benefits sought regarding this claim for service connection, it is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). Unfortunately, the Veteran's remaining claims must be remanded for further development. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims, so he is afforded every possible consideration. 1. Whether new and material evidence has been presented to reopen a claim for service connection for a low back disability, to include as secondary to service-connected residuals of right total shoulder arthroplasty, is remanded. 2. Entitlement to service connection for a neck disability, to include as secondary to service-connected residuals of right total shoulder arthroplasty, is remanded. 3. Entitlement to service connection for headaches, to include as secondary to service-connected residuals of right total shoulder arthroplasty, is remanded. The Veteran's claims were remanded in October 2020, in part, to obtain his complete service treatment records, including all clinical records of any inpatient treatment at Madigan General Hospital in 1971 and Brooke Army Hospital. The Veteran's service treatment records demonstrate that he was admitted to Brooke General Hospital, Fort Sam Houston, Texas on January 22, 1972 and was discharged on March 14, 1972. He was also admitted to Brooke General Hospital on April 7, 1972 and was discharged on June 7, 1972. Pursuant to the Board's instructions, additional service treatment records were obtained. The Veteran's service treatment records obtained following the October 2020 Board remand do not contain the-above referenced clinical records. These clinical records may have been filed separately. These records are particularly important as the Veteran maintains that he complained of headaches, neckaches, and backaches while hospitalized and on sick call during his active service and that his service treatment records do not contain 8 to 16 weeks of hospitalization. See July 2010 VA Form 21-4138, Statement in Support of Claim. Therefore, a remand is required to allow VA to make further efforts to obtain these records. Additionally, pursuant to the Board's remand directives, the Veteran was afforded a March 2021 Headache Disability Benefits Questionnaire. The examination report indicates that he has a diagnosis of occipital headaches and the date of diagnosis is listed as 1972. The Veteran's claims folder also contains a corresponding March 2021 medical opinion concerning the etiology of his occipital headaches. In particular, the medical opinion provides that the Veteran's claimed condition is less likely than not related to his active service as his headache during service was acute only. There is no evidence of chronicity of care and his symptoms are subjective only. The Board finds that the March 2021 medical opinion is inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In support, the medical opinion fails to provide any meaningful analysis or discussion of the Veteran's service treatment records and post-service VA treatment records regarding his complaints and treatment for headaches. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."); see also Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992) (reflecting that the Board is free to assess medical evidence and is not obligated to accept a physician's opinion). Additionally, there is no showing that the examiner considered the Veteran's lay statements regarding the onset of his headaches during his active service. See Miller v. Wilkie, 32 Vet. App. 249 (2020) (holding that the Board errs when it relies on an examination that fails to consider the veteran's relevant statements and the Board is silent on the credibility of these statements). Thus, an addendum medical opinion is warranted to address the nature and etiology of the Veteran's headache disability. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records from March 2021 to the present. 2. Obtain records of all inpatient treatment (i.e., clinical records) of the Veteran during his active service, including from Madigan General Hospital in 1971 and Brooke Army Hospital from January 22, 1972 to March 14, 1972 and April 7, 1972 to June 7, 1972. Document all requests for information as well as all responses in the Veteran's claims folder. If attempts to obtain any records are not successful, the Veteran must be notified of this fact and all efforts to obtain them must be documented and associated with his claims folder. 3. After the above development is completed, obtain an addendum medical opinion from an appropriate clinician concerning the nature and etiology of the Veteran's headache disability. The clinician must review the Veteran's claims folder. (a.) The clinician must provide an opinion as to whether any identified headache disability at least as likely as not (50 percent or greater probability) had its clinical onset during service or is related to any incident of service. In providing this opinion, the clinician should consider the following medical evidence: The service treatment record showing that the Veteran lost consciousness as a result of a motor vehicle accident in March 1973; The service treatment record showing that the Veteran complained of a headache after being hit in the face in May 1973it was noted that he slept well after having two val. and his headache somewhat improved; The post-service VA treatment records showing that the Veteran was treated for headaches in December 1974, January 1975 and February 1975; The post-service November 1975 VA treatment record noting the Veteran's history of a closed head injury in October 1975 when he attempted suicide by driving his car into a tree, with complaints of headaches in the morning; The post-service VA treatment record showing treatment for bitemporal headaches in February 1976; The clinician should consider the following lay evidence: The Veteran's statement that his headaches began in 1972 while he was at Fort Sam Houston, Texas when he sustained a broken jaw during a physical altercation and a whiplash injury; (Continued on the next page) The Veteran's statement that he complained of headaches while hospitalized and on sick call during his active service. The complete rationale for all opinions expressed must be set forth by the clinician. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sean Mussey, 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.